Case management touches every aspect of the health care continuum and is defined by the Case Management Society as: “a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.”
At Martin Health System, case management is focused on four major patient service areas: the emergency department, inpatient hospital care, utilization review and post hospitalization.
Emergency Department
The ED case manager, in coordination with the ED health care team, is responsible for determining the admission class of patients, ensuring the completeness of clinician documentation to determine patient class (observation versus inpatient), facilitating the interdisciplinary plan of care with a focus on evaluating the appropriateness of clinical care, medical necessity, admission status, level of care, and resource management, and coordination of services to obtain management for patients that are not appropriate for a hospital level stay. This individual initiates activities that promote quality outcomes and patient throughput.
The ED case manager, in coordination with the ED health care team, is responsible for determining the admission class of patients, ensuring the completeness of clinician documentation to determine patient class (observation versus inpatient), facilitating the interdisciplinary plan of care with a focus on evaluating the appropriateness of clinical care, medical necessity, admission status, level of care, and resource management, and coordination of services to obtain management for patients that are not appropriate for a hospital level stay. This individual initiates activities that promote quality outcomes and patient throughput.
Inpatient Care
The inpatient case manager is accountable for meeting our patients’ needs and promoting efficient and proper use of resources by working with the physician and the health care team to ensure an appropriate transition to the next level of care which can include: acute rehab, skilled nursing facility, palliative care, hospice, and home health care. Each case manager has a designated patient caseload to plan effectively and to design a plan of care that meets each individual patient’s needs, manages the length of stay, and promotes efficient utilization of resources through collaboration with the patient and/or family and all members of the health care team. The patient population and support systems can often be complex and may include undocumented aliens, and individuals who are homeless, pending social security disability or Medicaid-pending with critical or complex health care issues.
The inpatient case manager is accountable for meeting our patients’ needs and promoting efficient and proper use of resources by working with the physician and the health care team to ensure an appropriate transition to the next level of care which can include: acute rehab, skilled nursing facility, palliative care, hospice, and home health care. Each case manager has a designated patient caseload to plan effectively and to design a plan of care that meets each individual patient’s needs, manages the length of stay, and promotes efficient utilization of resources through collaboration with the patient and/or family and all members of the health care team. The patient population and support systems can often be complex and may include undocumented aliens, and individuals who are homeless, pending social security disability or Medicaid-pending with critical or complex health care issues.
Utilization Review (UR)
Case management works hand-in-hand with UR to facilitate the clinical information necessary for certification and/or payer authorization at the time of admission and throughout the entire hospitalization.
Case management works hand-in-hand with UR to facilitate the clinical information necessary for certification and/or payer authorization at the time of admission and throughout the entire hospitalization.
Post-Hospitalization
The post-acute care navigator uses appropriate nursing and case management processes to provide optimal quality and continuity of care from the pre-operative setting through the 90-day global period. The care navigator develops a plan of care for each patient’s physical, mental and social needs based on pre-surgical and ongoing clinical assessment. Care plans are individually implemented and modified throughout the continuum of care to ensure favorable patient transitions. During the post-acute phase, the care navigator will follow, monitor and troubleshoot when needed to make certain that the patient’s plan of care in the post-acute setting is complete. This may include, but is not limited to: making sure follow-up appointments are made and medications are obtained and understood; and coordinating nursing and case management interventions to ensure well-being and the desired outcomes.
The post-acute care navigator uses appropriate nursing and case management processes to provide optimal quality and continuity of care from the pre-operative setting through the 90-day global period. The care navigator develops a plan of care for each patient’s physical, mental and social needs based on pre-surgical and ongoing clinical assessment. Care plans are individually implemented and modified throughout the continuum of care to ensure favorable patient transitions. During the post-acute phase, the care navigator will follow, monitor and troubleshoot when needed to make certain that the patient’s plan of care in the post-acute setting is complete. This may include, but is not limited to: making sure follow-up appointments are made and medications are obtained and understood; and coordinating nursing and case management interventions to ensure well-being and the desired outcomes.
In celebration of Case Management Week, October 9 – 15, please join us in acknowledging and supporting all of our colleagues in case management and utilization review for the important work they do!