Facility Case Management Program Order Instructions: The Session Long Project for this course is to evaluate and critique a health care facility you are familiar with and compare it to the general principles and standards for quality assurance presented in this course.
In the earlier modules, you identified a health care facility for the subject of the SLP and presented a description of the facility and its quality assurance program. You also critiqued the facility’s Continuous Quality Improvement program and the Utilization Management Program.
In this module, you will discuss and critique the subject facility’s Case Management program.
Facility Case Management Program SLP Assignment Expectations
For this module you are to complete the following tasks in a 4- to 5-page paper:
•Describe and discuss the facility’s Case Management program.
•Compare and critique the subject facility’s Case Management program to that of a model facility and whether the facility adheres to the recognized standard for case management, including disease state management.
•Determine if the facility’s quality assurance program results in the patients being helped to maximize their health care benefits.
•Identify areas for improvement in the facility’s Case Management program, if any, and any recommendations you think should be implemented to improve the quality of patient care.
Background
Facility Case Management Program Case Management
Collins, D., Jarrah, Z., Gilmartin, C., & Saya, U. (2014). The costs of integrated community case management (iCCM) programs: A multi-country analysis. Journal of Global Health.
Curtis, J. L., Millman, E. J., Struening, E. L., & D’Ercole, A. (2014). Does outreach case management improve patients’ quality of life?. Psychiatric services.
Hendricks, V., Schmidt, S., Vogt, A., Gysan, D., Latz, V., Schwang, I., Riedel, R. (2014). Case Management Program for Patients With Chronic Heart Failure: Effectiveness in Terms of Mortality, Hospital Admissions, and Costs. Deutsches Ärzteblatt International, 111(15), 264–270. http://doi.org.ezproxy.trident.edu:2048/10.3238/arztebl.2014.0264
Moreo, K., Moreo, N., Urbano, F. L., Weeks, M., & Greene, L. (2014). Are We Prepared for Affordable Care Act Provisions of Care Coordination? Case Managers’ Self-Assessments and Views on Physicians’ Roles. Professional Case Management. 19(1), 18-26.
Mullahy, C. M. (2014). The Case Manager’s Handbook, (5thed). Burlington, MA: Jones & Bartlett Learning. Retrieved from: http://books.google.com/books?hl=en&lr=&id=iUPyAAAAQBAJ&oi=fnd&pg=PA12&dq=concurrent+utilization+review+programs+in+nursing+homes&ots=iorEmkFyuh&sig=4YnmC-9Hh6jCoi0rK2dH58NhoIM#v=onepage&q&f=false
Phillips, R. L., Han, M., Petterson, S. M., Makaroff, L. A., & Liaw, W. R. (2014). Cost, Utilization, and Quality of Care: An Evaluation of Illinois’ Medicaid Primary Care Case Management Program. Annals of Family Medicine, 12(5), 408–417. http://doi.org.ezproxy.trident.edu:2048/10.1370/afm.1690
Talisman, N., Kaltman, S., Davis, K., Sidel, S., Akil, M., & Alter, C. (2015). Case Management: A New Approach. Psychiatric Annals, 45(3), 134.
Young, M., Sharkey, A., Aboubaker, S., Kasungami, D., Swedberg, E., & Ross, K. (2014). The way forward for integrated community case management programmes: A summary of lessons learned to date and future priorities. Journal of Global Health, 4(2), 020303. http://doi.org.ezproxy.trident.edu:2048/10.7189/jogh.04.020303
Modular Learning Outcomes
Upon successful completion of this module, the student will be able to satisfy the following outcomes:
• Case Discuss and explain the importance of case management within the context of quality assurance programs.
• SLP Compare case management within the context of quality assurance programs to a model program.
• Discussion Debate the utility of Social Health Maintenance Organizations (SHMOs).
Facility Case Management Program Module Overview
Introduction
Case management, which is sometimes referred to as care management, is frequently used for patients that have complex problems and require numerous services over an extended period of time. Case management programs are sometimes called Rare and Expensive Case Management programs by some healthcare organizations.
Regardless of the type of case management program, they all have a similar purpose to coordinate the care and treatment for patients with serious and life-threatening conditions over an extended period of time. An example of an illness which requires both medical and social services are Acquired Immune Deficiency Syndrome (AIDS), spinal cord injury, and paraplegics.
Case managers are usually not involved with the patient and their treating physician where primary care needs are limited. However, when a patient requires long-term care, specially trained case managers may be able to more efficiently coordinate and monitor the delivery of health care services. In this role, the case manager can have a positive impact on the quality of services provided to the patient.
Case managers always consult with primary and secondary care providers to determine what care is required and they arrange for patients to receive the agreed-upon care in the most appropriate and cost-effective setting.
Actually, case managers are often thought of as gatekeepers because of their role in controlling utilization of health care services. In the role of a gatekeeper, the case manager coordinates hospital admissions, surgical consultation, specialist consultation, diagnostic testing, and social services. They also make secondary care referrals and are usually involves a primary care delivery consultations.
Case management has evolved over the years as a specialty position in many health care organizations. For instance, case managers can specialize in home health care, rehabilitation, long-term care, mental health, hospitalization inpatient surgery, outpatient surgery, and even surgical evaluation.
Other areas of case management where specialized skills are required are in the area of Disease State Management, transplant facilities, and high-risk pregnancies.
Case management has become an important element for providing quality care and certainly should be part of every quality assurance program.
Facility Case Management Program Sample Answer
Facility’s case management program
Case Management is a vital component of the Durham VA healthcare facility. Case management refers to the specialized and skilled component of patient care program that involves coordination of care to improve the quality of care at an affordable cost in patients diagnosed with chronic and complex healthcare condition. The main aim of this case management program is to implement and to facilitate integrated services that will enhance collaborated care and to reduce the cost of care (Durham.va, 2015).
Case management process begins as soon as the patient is assigned to a case manager. The case manager discusses with the patient on various aspects of their lives in order to identify patient goals and barriers to achieving these goals. The case manager develops a plan and is active throughout the case management process. Thereafter, the case manager coordinates the interdisciplinary teams involved including physicians, physiotherapist, mental health and other involved healthcare providers. Throughout the case management process, the case manager is expected to monitor and to evaluate patient’s outcome, and to adjust the plan as needed to assist the patient to achieve goals to optimize their level of wellbeing and independence (VHA Handbook, 2013).
Compare and critique facility case management program to that of the model case management program
According to the module, the case management program is mainly applied in patients with complex healthcare complications that need numerous healthcare services. The case managers in the module are only slightly involved with treating physician if the primary care demands are limited, but they are widely involved in patients who need long term care in order to coordinate and to monitor effective delivery of healthcare services. In this case, the case manager has a positive impact on the quality of services delivered (Hendricks et al., 2014).
At Durham VA, case management process is quite similar as that described in the module. The case managers consult with the secondary and the primary care providers so as to determine patient care needed and the most cost-effective cost. Similar to the modules, the case managers also play the role of gatekeepers at VA healthcare facility. In the role of gatekeeping, the case managers coordinate hospital admissions, specialist consultation, surgical consultation as well as providing social services. If necessary, the case managers make care referrals (VHA Handbook, 2013).
VA health facility adheres to the standard protocol for case management such as disease state management. For instance, a case manager is expected to intervene using specific actions at varying degree of intensity based on patient health status and continuum of care based on the bio-psychosocial presentation of the patient. The elements of the case management process at VA healthcare facility begin with the identification of the patient to be case managed. This can be through referral or self-referral. The patient is asked to give consent to case management processes. The second element is that of a comprehensive assessment of the patient needs, which is completed by the case manager. Reassessment is done using utilization management criteria to ensure that the patient is given appropriate care and that the care provided is cost effective. During the assessment, the patient problem is identified, problem-solving is achieved and goals and outcomes are identified. This is followed by a resource assessment to identify available resources and alternative sources for resources that are not available (Hendricks et al., 2014).
The next phase of the case management process at VA is planning and implementation which is accomplished through collaboration, coordination and effective communication with the involved interdisciplinary team. The duration and intensity of case management process are determined by the patient’s health condition and care needs. For transitions and referrals is done in a timely manner so as to ensure that the patient reaches appropriate care in time. The case manager is responsible for coordinating transition as well as referrals (VHA Handbook, 2013).
To ensure that a patient receives care at the right time, place, and cost, the case manager is expected to continuously monitor and evaluate the case management process. This ensures that the patient receives services that are effective, timely, evidence base, cost-effective and of high quality. The evaluation process is done for continuous performance improvements and to ensure that the case management program is efficient, of high quality and sustainable (Curtis, Millman, Struening, & D’Ercole, 2014).
Quality assurance program maximizes health care benefits
The quality assurance program at VA healthcare facility aims at maximizing healthcare benefits. The program focuses and sets priorities to improve performance by focusing on high risk and areas prone to these risks, to assess the prevalence, severity of the problems in the areas so as to improve health outcomes, patient safety as well as the quality of care. Some of the areas quality-based program at VA focuses on includes high-risk procedures, medication errors, patient errors, equipment malfunctions and related problems, deviations from treatment protocols and patient safety outcomes (Collins, Jarrah, Gilmartin, & Saya, 2014).
The quality program activities include tracking errors and their adverse effects. The quality program also analyzes the cause in order to identify the collective as well as collective compliance health issues. These issues are considered as learning opportunities as they help the health care facility quality department is able to develop strategic preventive measures, which are continuously monitored to ensure new knowledge gaps are identified and the improvements are sustained. Some of the interventions and methods used to address compliance include system related interventions, routine equipment improvements, education and remedial pieces of training to VA staffs. At this healthcare facility, the quality assurance/ quality improvement system includes regular review of trip records in accordance to hospitals QA/QI protocols and standards (VHA Handbook, 2013).
The quality assurance has improved outcomes for the organization and the institution. In addition, the program has led to improvements on operations such as faster billing system, faster test results, patient flow, and efficient data recording and sharing with minimal patient and medical errors. The health-related outcome includes a reduction in hospital-acquired infections, lengthened hospital stays and mortality rates. The work environment has been improved to ensure increased patient satisfaction, improved staff morale and retention and the healthcare facility reputation in the community. Bottom line, the program has led to the decreased cost of care (Hendricks et al., 2014).
Areas of improvement in healthcare facility case management program
Evidently, the quality assurance program has led to numerous health benefits. However, the main challenges that I have noticed in this healthcare facility in regards to implementation of quality programs include resistance by staff, limited resources to maintain quality related investments and complacency with previous improvements (Mullahy, 2014).
Lessons learned from this program that will assist in establishing a culture of quality include involving the staff during problem identification processes and developing of problem-solving strategies. This is because it is the staff that actually experiences these challenges. Most importantly, the quality assurance program must balance quality with financial goals because investments in healthcare settings quality improvement could have long-term or short-term impacts (Hendricks et al., 2014).
Facility Case Management Program References
Durham.va (2015). Durham VA Medical Center: Retrieved from http://www.durham.va.gov/
VHA Handbook. (2013). Case management standards of practice. Retrieved from http://www.va.gov/optometry/docs/vha_handbook_1110-04_case_management_standards_of_practice.pdf
Collins, D., Jarrah, Z., Gilmartin, C., & Saya, U. (2014). The costs of integrated community case management (iCCM) programs: A multi– country analysis. Journal of Global Health.
Curtis, J. L., Millman, E. J., Struening, E. L., & D’Ercole, A. (2014). Does outreach case management improve patients’ quality of life?. Psychiatric services.
Hendricks, V., Schmidt, S., Vogt, A., Gysan, D., Latz, V., Schwang, I., Riedel, R. (2014). Case Management Program for Patients With Chronic Heart Failure: Effectiveness in Terms of Mortality, Hospital Admissions, and Costs. Deutsches Ärzteblatt International, 111(15), 264–270. http://doi.org.ezproxy.trident.edu:2048/10.3238/arztebl.2014.0264
Mullahy, C. M. (2014). The Case Manager’s Handbook, (5thed). Burlington, MA: Jones & Bartlett Learning. Retrieved from:
http://books.google.com/books?hl=en&lr=&id=iUPyAAAAQBAJ&oi=fnd&pg=PA12&dq=concurrent+utilization+review+programs+in+nursing+homes&ots=iorEmkFyuh&sig=4YnmC-9Hh6jCoi0rK2dH58NhoIM#v=onepage&q&f=false
