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Case Management

The goals of case management are to facilitate:

  1. timely discharges
  2. prompt, efficient use of resources
  3. achievement of expected outcomes
  4. collaborative practice
  5. coordination of care across the continuum
  6. performance improvement activities which lead to optimal patient outcomes

Service-based registered nurses monitor the utilization and quality of health-care services and intervene as necessary.

In several different environments, a case manager can be described as different things for different services. A social worker can be defined as a case manager, especially in a mental health setting. They are the case managers accountable for their clients continuing to access the systems available in their area.

A nurse case manager can be defined in three different ways. In some hospitals or hospital systems, there are three integral parts that create a case manager. Some are independent, a combination of one, or all of the below criteria.

Utilization Review Manager: Either by the hospital or by the insurance company that runs the hospital, these 'case managers' review charts for the use of interdependent hospital systems, timeliness of service as well as safe and appropriate 'utilization' of services, URM is the department that's accountable for other private insurance's certifying and approving acute and non-acute hospital stays, with the information provided by the URM nurse. The URM nurse uses the InterQual Criteria, a standardized schematic of diagnosis, procedural transactions, possible complications, and standardized timelines in which to account for the changing diagnosis.

The URM nurse works closely with a UR/QM physician for monitoring quality services to the patient. If after review of the patient's stay and utilization of services, a patient no longer needs the stay in an acute care setting, the URM nurse may request that the patient have outpatient or other services provided for the patient to the attending. If the attending physician is not in agreement, the URM nurse may contact this UR/QM physician liaison. This is usually one of the many attending physicians already at that current hospital; or in some cases, the physician that is the director of that HMO/PPO. This physician will review the chart, current prognosis and discharge plan. If the Physician Liaison agrees with the URM nurse, this physician will essentially go over the attending physician's head to discharge the patient to the next lower level of care. It usually occurs as a conversation between physicians, so that the attending physician can still make integral decisions on his patient's behalf.

To be an effective URM nurse, at least 3 years of acute hospital tenure is recommended. This being that the RN can have experience with standard procedures, and timeliness of outcomes with the possible expected complications.

Quality Management: In most hospitals this portion is usually independent of Case Management. But, the smaller the hospital, the smaller the budget for such things. QM or QRM nurse, much like a URM nurse is accountable for the overall quality of care being delivered. This nurse may also be found in the Risk Management office working with the hospitals risk management team, 'putting out' any legal fires that may occur during a patient's hospital stay. Again, this nurse will also work with the QM physician and attorney liaison.

Discharge Planner: A discharge planner is a nurse that coordinates all the facets of a patient's admission/discharge. Through the InterQual Criteria, this nurse evaluates all high-risk patients (over the age of 6 or 70, depending on the hospital), with high-risk diagnosis, i.e. stroke, MI, complicated pneumonia. It is the discharge planner that plays investigative reporter, making available all the social and financial resources that the high-risk patient has. This is done for the purpose of a safe and viable discharge plan set originally by the DRG's. The nurse uses his/her experience and assessment skills reviewing the patient's current course, past medical history and o, of course, what family/friend support there is outside the hospital. The discharge planner is also familiar with Medicare/medi-cal guidelines, InterQual criteria, and fee for service items that would qualify a patient for another level of care. Example: SNF stay, sub acute stay or outpatient, home care referrals. The discharge planner, depending on the hospital can cover up to 40 patients or more. The ideal system would be no more than 20.

Given the current standard of pay and accountability the discharge-planning nurse has, not many nurses are interested in this field. Its schedule, Monday through Friday, 9-5 is the only really attractive piece for most RN's.

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