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Outpatient Case Management for Adults With Medical Illness and Complex Care Needs

Outpatient Case Management for Adults With Medical Illness and Complex Care Needs
Author: U. S. Department Human Services
Publisher: Createspace Independent Publishing Platform
Total Pages: 0
Release: 2013-04-10
Genre:
ISBN: 9781484086117

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Chronic diseases are the leading cause of illness, disability, and death in the U.S. Providing medical care for chronic illness is often complex, as patients require multiple resources, treatments, and providers. One strategy for improving care for chronic conditions is to develop programs that improve care coordination and implement care plans. Case management (CM) is one such supplemental service, in which a person takes responsibility for coordinating and implementing a patient's care plan, either alone or in conjunction with a team of health professionals. CM tends to be more intensive in time and resources than other chronic illness management interventions, and it is important to evaluate its specific value. CM is often utilized when the coordination and integration of care is difficult for patients to accomplish on their own. CM usually involves high-intensity engagement with patients, and case managers often adopt a supervisory role in comprehensively attending to patients' complex needs. Conceptually, a case manager can be seen as an agent of the patient, taking a "whole-person" (rather than solely clinical or disease-focused) approach to care, and serving as a bridge between the patient, the practice team, the health system, and community resources. The coordinating functions performed by a case manager include helping patients navigate health care systems, connecting them with community resources, orchestrating multiple facets of health care delivery, and assisting with administrative and logistical tasks. Case managers also can perform clinical functions, including disease-oriented assessment and monitoring, medication adjustment, health education, and self-care instructions. Such clinical functions are often the defining aspects of other chronic illness management interventions. In the context of chronic illness care, they are central to the role of a case manager, but a case manager also performs coordinating functions. The Agency for Healthcare Research and Quality (AHRQ) commissioned this review to examine the evidence for the effectiveness of CM programs for chronic illness patients with complex care needs. Specifically, we considered interventions in which case managers had a substantive role in performing both clinical and coordinating functions. This report summarizes the existing evidence addressing the following Key Questions: KQ1: In adults with chronic medical illness and complex care needs, is case management effective in improving: a. Patient-centered outcomes, including mortality, quality of life, disease-specific health outcomes, avoidance of nursing home placement, and patient satisfaction with care? b. Quality of care, as indicated by disease-specific process measures, receipt of recommended health care services, adherence to therapy, missed appointments, patient self-management, and changes in health behavior? c. Resource utilization, including overall financial cost, hospitalization rates, days in the hospital, emergency department use, and number of clinic visits (including primary care and other provider visits)? KQ2: Does the effectiveness of case management differ according to patient characteristics, including but not limited to: particular medical conditions, number or type of comorbidities, patient age and socioeconomic status, social support, and/or level of formally assessed health risk? KQ3: Does the effectiveness of case management differ according to intervention characteristics, including but not limited to: practice or health care system setting; case manager experience, training, or skills; case management intensity, duration, and integration with other care providers; and the specific functions performed by case managers?


Outpatient Case Management for Adults with Medical Illnesses and Complex Care Needs

Outpatient Case Management for Adults with Medical Illnesses and Complex Care Needs
Author: Annette Marie Totten
Publisher:
Total Pages:
Release: 2013
Genre:
ISBN:

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In 2010, the Agency for Healthcare Research and Quality (AHRQ) charged the Oregon Evidence-based Practice Center (EPC) with conducting a review to evaluate the comparative effectiveness of outpatient case management (CM) as an intervention strategy for chronic illness management. The aims of the review were to assess the evidence pertaining to the effectiveness of CM in improving patient-centered outcomes, quality of care, and resource utilization in adults with chronic medical illness and complex care needs. It also evaluated the effectiveness of CM based on patient and intervention characteristics. After synthesizing the results from 109 studies, the original Comparative Effectiveness Review (CER) concluded that, while there were a number of approaches to CM matching the review's definition and scope, the interventions had limited impact on patient-centered outcomes, quality of care, and resource utilization among patients with chronic medical illness. Nevertheless, the review was able to identify some clinical settings in which CM had positive (though modest) effects on these outcomes. The objective of this Future Research Needs (FRN) project was to engage a range of stakeholders and combine their insight with the results of the CER and a scan of the recent literature and studies in progress. Drawing from all these sources we sought to identify and prioritize topics for future research that could inform health care decisionmaking and policy regarding CM.


Outpatient Case Management for Adults with Medical Illness and Complex Care Needs

Outpatient Case Management for Adults with Medical Illness and Complex Care Needs
Author: David H. Hickam
Publisher:
Total Pages:
Release: 2013
Genre:
ISBN:

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OBJECTIVES: In this evidence review we evaluated outpatient case management (CM) as an intervention strategy for chronic illness management. We summarized the existing evidence related to the effectiveness of CM in improving patient-centered outcomes, quality of care, and resource utilization in adults with chronic medical illness and complex care needs. We also assessed the effectiveness of CM according to patient and intervention characteristics. DATA SOURCES: Articles were identified from searches of the MEDLINE(r), CINAHL(r), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects. The databases were searched through August 2011. REVIEW METHODS: Two reviewers evaluated abstracts and articles against prespecified inclusion criteria. Eligible studies were quality rated and data were extracted, entered into tables, and summarized. Due to the heterogeneity of outcomes, meta-analyses were not conducted. Systematic reviews were retrieved for reference, but data from pooled results of published reviews were not included in our analysis. RESULTS: Of the 5,645 citations identified, we screened and reviewed 1,201 full-length articles and included 153 articles representing 109 studies. Many of the published trials of CM examined programs that targeted specific patient conditions, and the approaches to CM were diverse. Overall, the interventions tested in the studies were associated with only small changes in patient-centered outcomes, quality of care, and resource utilization. While CM can improve some types of health care utilization, there are minimal effects on overall costs of care. For selected populations, the characteristics of successful interventions included intense CM with greater contact time, longer duration, face-to-face visits, and integration with patients' usual care providers. CONCLUSIONS: Recognizing the heterogeneity of study populations, interventions, and outcomes, we sought to elucidate the conditions under which CM was effective. We found that CM had limited impact on patient-centered outcomes, quality of care, and resource utilization among patients with chronic medical illness.


Outpatient Case Management for Adults with Medical Illnesses and Complex Care Needs: Future Research Needs

Outpatient Case Management for Adults with Medical Illnesses and Complex Care Needs: Future Research Needs
Author: U. S. Department Human Services
Publisher: CreateSpace
Total Pages: 78
Release: 2014-05-11
Genre:
ISBN: 9781499519716

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In 2010, the Agency for Healthcare Research and Quality (AHRQ) charged the Oregon Evidence-based Practice Center with conducting a Comparative Effectiveness Review (CER) to assess the effectiveness of outpatient case management as an intervention strategy for chronic illness management. The Key Questions the review addressed were: Key Question 1. In adults with chronic medical illness and complex care needs, is case management effective in improving: 1a. Patient-centered outcomes, including mortality, quality of life, disease-specific health outcomes, avoidance of nursing home placement, and patient satisfaction with care? 1b. Quality of care, as indicated by disease-specific process measures, receipt of recommended health care services, adherence to therapy, missed appointments, patient self-management, and changes in health behavior? 1c. Resource utilization, including overall financial cost, hospitalization rates, days in the hospital, emergency department use, and number of clinic visits (including primary care and other provider visits)? Key Question 2. Does the effectiveness of case management differ according to patient characteristics, including but not limited to: particular medical conditions, number or type of comorbidities, patient age and socioeconomic status, social support, and/or level of formally assessed health risk? Key Question 3. Does the effectiveness of case management differ according to intervention characteristics, including but not limited to: practice or health care system setting; case manager experience, training, or skills; case management intensity, duration, and integration with other care providers; and the specific functions performed by case managers?


Physician's Guide

Physician's Guide
Author: Roger G. Kathol
Publisher: Humana Press
Total Pages: 337
Release: 2016-07-27
Genre: Medical
ISBN: 3319289594

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Improving the outcomes for patients in our changing healthcare system is not straightforward. This grounding publication on case management helps physicians better meet the unique needs of patients who present with poor health and high healthcare-related costs, i.e., health complexity. It details the many challenges and optimal practices needed to work effectively with various types of case managers to improve patient outcomes. Special attention is given to integrated case management (ICM), specifically designed for those with health complexity. The book provides a systematic method for identifying and addressing the needs of patients with biological, psychological, social, and health-system related clinical and non-clinical barriers to improvement. Through ICM, case managers are trained to conduct relationship-building multidisciplinary comprehensive assessments that allow development of prioritized care plans, to systematically assist patients to achieve and document health outcomes in real time, and then graduate stabilized patients so that others can enter the case management process. Patient-centered practitioner-case manager collaboration is the goal. This reference provides a lexicon and a roadmap for physicians in working with case managers as our health system explores innovative ways to improve outcomes and reduce health costs for patients with health complexity. An invaluable, gold-standard title, it adds to the literature by capturing the authors' personal experiences as clinicians, researchers, teachers, and consultants. The Physician's Guide: Understanding and Working With Integrated Case Managers summarizes how physicians and other healthcare leadership can successfully collaborate with case managers in delivering a full package of outcome changing and cost reducing assistance to patients with chronic, treatment resistant, and multimorbid conditions.


The Integrated Case Management Manual

The Integrated Case Management Manual
Author: Roger G. Kathol
Publisher: Springer
Total Pages: 335
Release: 2018-06-14
Genre: Medical
ISBN: 3319747428

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Thoroughly revised and updated since its initial publication in 2010, the second edition of this gold standard guide for case managers again helps readers enhance their ability to work with complex, multimorbid patients, to apply and document evidence-based assessments, and to advocate for improved quality and safe care for all patients. Much has happened since Integrated Case Management (ICM), now Value-Based Integrated Case Management (VB-ICM), was first introduced in the U.S. in 2010. The Integrated Case Management Manual: Valued-Based Assistance to Complex Medical and Behavioral Health Patients, 2nd Edition emphasizes the field has now moved from “complexity assessments” to “outcome achievement” for individuals/patients with health complexity. It also stresses that the next steps in VB-ICM must be to implement a standardized process, which documents, analyzes, and reports the impact of VB-ICM services in removing patient barriers to health improvement, enhancing quality and care coordination, and lowering the financial impact to patients, providers, and employer groups. Written by two expert case managers who have used VB-ICM in their large fully disseminated VB-ICM program and understand its practical deployment and use, the second edition also includes two authors with backgrounds as physician support personnel to case managers working with complex individuals. This edition builds on the consolidation of biopsychosocial and health system case management activities that were emphasized in the first edition. A must-have resource for anyone in the field, The Integrated Case Management Manual: Value-Based Assistance to Complex Medical and Behavioral Health Patients, 2nd Edition is an essential reference for not only case managers but all clinicians and allied personnel concerned with providing state-of-the-art, value-based integrated case management.


COLLABORATE(R) for Professional Case Management

COLLABORATE(R) for Professional Case Management
Author: Teresa Treiger
Publisher: Lippincott Williams & Wilkins
Total Pages: 623
Release: 2015-04-15
Genre: Medical
ISBN: 1496319435

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This book is about the progressive improvement of case management beyond that which it exists to that of a practice specialty focused on professionalism and collegiality across all practice settings. Our desire to produce a framework for such practice began when we connected several years ago. It was a result of a dialogue; the sharing of our stories and experiences. Separately, we were already passionate about and committed to case management excellence. Together, our vision coalesced to form this competency-based framework for advancing case management captured by an acronym which defined the essence of professional practice---COLLABORATE. We spent hours discussing the implications of a perceived epidemic involving less than productive interactions between individuals working under the title of case manager with consumers, providers, and clinical colleagues. These accumulated experiences heightened our commitment to lead much-needed change. Our conversation endured over many months as we realized a shared: Respect for case management’s rich heritage in healthcare, across professional disciplines and practice settings; Concern for those factors which devalue case management’s professional standing; Agreement that while the practice of case management transcends many representative professional disciplines and educational levels, each stakeholder continues to cling to their respective stake in the ground; and Belief of the importance for case management to move from advanced practice to profession once and for all. COLLABORATE was borne from a vision; the mandate to solidify a foundation for case management practice which combines unique action-oriented competencies, transcends professional disciplines, crosses over practice settings, and recognizes educational levels. The ultimate focus is on improving the client’s health care experience through the promotion of effective transdisciplinary collaboration. COLLABORATE recognizes the hierarchy of competencies and practice behaviors defined by the educational levels of all professionals engaged; associate, bachelors, masters and doctoral degrees across practice disciplines. Through this approach, every qualified health and human service professional has a valued place setting at case management’s ever-expanding table. Each of the competencies are presented as mutually exclusive and uniquely defined however, all are complementary and call on the practitioner to conduct work processes in a wholly integrated manner. While appearing in order for the acronym’s sake, they are not necessarily sequential. Ultimately, case management is an iterative process. When united in a comprehensive and strategic effort, the COLLABORATE competencies comprise a purpose-driven, powerful case management paradigm. The agility of this model extends to use of key concepts that include both action-oriented verbs and nouns, which are significant elements in any professional case management endeavor. To date, case management practice models have been driven by care setting and/or business priorities. Unfortunately, this exclusivity has contributed to a lack of practice consistency due to shifting organizational and regulatory priorities. However, this is only one reason for a fragmented case management identity. COLLABORATE recognizes and leverages these important influencers as critical to successful practice and quality client outcomes. Interprofessional education and teamwork are beginning to emerge as the means to facilitate relationship-building in the workplace. Through this approach, health care practitioners absorb the theoretical underpinning of intentionally work together in a mutually respectful manner which acknowledges the value of expertise of each care team stakeholder. This educational approach provides the opportunity to engage in clinical practice that incorporates the professional standards to which we hold ourselves accountable Innovative and emerging care coordination models, defined by evidence-based initiatives, appear across the industry. Each promotes attention to interprofessional practice in order to achieve quality patient-centered care. Herein lies an opportunity to demonstrate the value drawn from diverse expertise of case managers comprising the collective workforce. However a critical prefacing stage of this endeavor involves defining a core practice paradigm highlighting case management as a profession. The diverse and complex nature of population health mandates that case management intervene from an interprofessional and collaborative stance. While inherent value is derived from the variety of disciplines, this advanced model unifies case management’s unique identity. Now is the time to define and adopt a competence-based model for professional case management. COLLABORATE provides this framework. This text is presented in four sections: Section 1: Historical validation of why this practice paradigm is critical for case management to advance to a profession; Section 2: Presentation of the COLLABORATE paradigm, with a chapter to devoted to each distinct competency and the key elements; Section 3: Practical application of the book’s content for use by the individual case manager and at the organizational level; and The Epilogue: Summarizes the COLLABORATE approach in a forward-looking context. For the reader with limited time, reviewing Section 2 provides the substantive meat associated with each of the competencies. Our ultimate desire is that the COLLABORATE approach provides an impetus for all stakeholders (e.g., practitioners, educational institutions, professional organizations) to take the necessary steps toward unified practice in order to facilitate the transition of case management considered as a task-driven job to its recognition as being a purpose-driven profession. The book provides a historical validation of why this new practice paradigm is critical for case management to advance as a profession; presents the COLLABORATE paradigm, with a chapter to devoted to each distinct competency and the key elements; and covers the practical application of the book’s content by individual case managers, and at the organizational level.


Core Skills for Hospital Case Managers

Core Skills for Hospital Case Managers
Author: Tony Cesta
Publisher: HC Pro, Inc.
Total Pages: 319
Release: 2009-06
Genre: Medical
ISBN: 1601463537

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Core Skills for Hospital Case Managers: A Training Toolkit for Effective Outcomes Toni Cesta, PhD, RN, FAAN; Beverly Cunningham, MS, RN As of June 20, 2014, contact hours for nurses are no longer available with this product. Finally--an affordable, effective, and consistent training program for your hospital case managers. This one-of-a-kind guide to fundamental case management responsibilities is a necessary reference tool for every hospital case management department. This resource is designed to give case management directors and hospital leaders the tools they need to build and strengthen the basic and advanced skills their case management staff needs to succeed. Core Skills for Hospital Case Managers is an orientation and training manual for nurses transitioning into case management, an easy-to-read reference guide for new case managers, and a source of inspiration, tools, and resources for seasoned professionals. With a flexible format, this book and CD-ROM offer practical information and customizable tools to develop and maintain a wide variety of care management skills. Table of contents Chapter 1: Hospital Case Management 101 Chapter 2: Case Manager Role Chapter 3: Roles, Functions, and Caseloads Chapter 4: The Case Management Process Chapter 5: The Case Manager's Role in Transitional and Discharge Planning Chapter 6: Utilization Management Chapter 7: Managing Long Length of Stay Patients Chapter 8: Denials: Prevention and Appeals Strategies Chapter 9: Reimbursement Chapter 10: The Role of the Case Manager in Patient Flow Chapter 11: Measuring Success: Strategic Outcome Measures Chapter 12: Dealing with the Uninsured and Underinsured Chapter 13: Working with Multidisciplinary Teams Chapter 14: Crucial Communication and Conflict Resolution Learning objectives: Discuss the evolution of hospital case management Explain the different models of hospital case management Determine the various goals of hospital case management Examine the various roles of case management Discuss the variety of functions performed by case managers Discuss the scope of the case manager position Examine staffing ratios in various models List the steps in the case management process Determine the role of case managers in documentation Examine case managers' role in discharge planning List the factors that influence the discharge planning process Determine strategies for improving discharge planning Discuss how hospital reimbursement affects utilization management (UM) List the stages of UM coordination Determine the affect of outside influences on UM Evaluate different payers' regulations regarding UM Examine case management's role in length of stay (LOS) Evaluate strategies for managing patients with long LOS Identify data used to track and trend LOS Evaluate the reasons behind denials Discuss case management's role in preventing denials Examine case management's roles in reversing denials Examine case management's role in reimbursement Determine strategies for effective case management related to reimbursement Evaluate case management's role in patient flow Discuss demand and capacity management Identify strategies for managing patient flow Identify measurable case management outcomes Explain how case managers can track quality outcome metrics Discuss other metrics case management departments can track and trend Examine ways to create a case management report card Discuss the unfunded or underfunded patient populations Describe the role of the ED case manager with unfunded or underfunded patient populations Evaluate strategies for dealing with unfunded or underfunded patient populations Examine strategies for successfully working with multidisciplinary teams Describe sources of conflict with which case managers frequently come in contact Discuss strategies for reducing conflict Intended audience Staff nurses, charge nurses, staff educators, staff development specialists, directors of education, nurse managers, and nurse leaders


CMSA’s Integrated Case Management

CMSA’s Integrated Case Management
Author: Rebecca Perez, MSN, RN, CCM, FCM
Publisher: Springer Publishing Company
Total Pages: 393
Release: 2023-09-15
Genre: Medical
ISBN: 0826188346

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Developed by the Case Management Society of America (CMSA), this manual provides case managers with the essential tools necessary to successfully support quality patient care within today's complex healthcare system. This updated and revised second edition addresses the role of the case manager and unpacks how to assess and treat patients with complex issues; including those who are challenged with medical and behavioural conditions and poor access to care services, as well as chronic illnesses and disabilities, and require multidisciplinary care to regain health and function. With a wealth of information on regulatory requirements, new models of care, integration of services, and new performance measures, chapters outline the steps needed to begin, implement, and use the interventions of the Integrated Case Management approach. Written by case managers for case managers, this practical manual presents the CMSA--tested approach toward systematically integrating physical and mental health case management principles and assessment tools. As the healthcare field continues to increase in complexity and given the constantly changing regulatory environment, healthcare workers must know how to integrate those new regulations, describe alternative payment options, and implement requirements for greater patient and family assessment, care planning, and care coordination in their practice. New to This Edition: Increased coverage and focus on Social Determinants of Health New chapters on support specialty populations including veterans, trauma survivors, maternal child health, children with special healthcare needs Simplified terminology and presentation of CMSA Assessment Grid and process Key Features Aligned with the Model Care Act, the CMSA Standards of Practice, and the CMSA Core Curriculum for Case Management Assists case managers enhance their ability to work with complex patients and learn how to apply new evidence-based assessments, as it fosters safe and high-quality care Teaches case managers to evaluate patients for medical and mental health barriers in order to coordinate appropriate integrated interventions and treatment planning Integrates biological, psychological, social and health system assessment Supports care of adult, elderly, and pediatric patient populations with complex issues


Definition of Serious and Complex Medical Conditions

Definition of Serious and Complex Medical Conditions
Author: Institute of Medicine
Publisher: National Academies Press
Total Pages: 127
Release: 1999-10-19
Genre: Medical
ISBN: 0309172608

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In response to a request by the Health Care Financing Administration (HCFA), the Institute of Medicine proposed a study to examine definitions of serious or complex medical conditions and related issues. A seven-member committee was appointed to address these issues. Throughout the course of this study, the committee has been aware of the fact that the topic addressed by this report concerns one of the most critical issues confronting HCFA, health care plans and providers, and patients today. The Medicare+Choice regulations focus on the most vulnerable populations in need of medical care and other services-those with serious or complex medical conditions. Caring for these highly vulnerable populations poses a number of challenges. The committee believes, however, that the current state of clinical and research literature does not adequately address all of the challenges and issues relevant to the identification and care of these patients.