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NURSING CASE MANAGEMENT
AND CRITICAL PATHWAYS OF
CARE
PRESENTED BY
MS JIYA G PANTHANALIL
IST YEAR MSC NURSING
NIMHANS, BAN...
INTRODUCTION
 Concept of case management evolved with advent of
diagnosis related groups (DRGs) and shorter hospital
stay...
DEFINITION
• Managed care refers to a strategy employed by
purchasers of health care services who make
determinations abou...
Managed care exists in many settings:
• Insurance –based programs
• Employer –based medical providerships
• Social service...
FEATURES OF CASE MANAGEMENT
• Method used to achieve managed care
• Actual coordination of services with in the
fragmented...
COMPONENTS
Case finding
Assessment
Care planning
Care co-ordination
CASE FINDING
• Systematic method
• identify individuals who are at risk of hospital
admissions
• Aims at preventing unplan...
ASSESSMENT
• Assessment of current level of ability
• Physical and social care needs
• Assessment is not restricted only t...
CARE PLANNING
Care plan address individuals’ full range of
needs including
• Health, personal, social, economic, educatio...
Care plan enables case manager to
• Make referrals to various services
• Co-ordinate all the different services he/she
sho...
• Care plan should be viewed as a live document
• Review the individual’s health and social care
needs and revise the care...
CARE CO-ORDINATION
Reduce duplications of
health care
Avoid gaps and reduce
health and social care service
costs
Improv...
COMMON ACTIVITIES IN CARE CO-ORDINATION
1. MEDICATION MANAGEMENT
-Ensure that individual’s medication regimen is appropria...
2. SELF CARE SUPPORT
Providing general health education and advice
Providing health education and advice specific to
ind...
3. ADVOCACY AND NEGOTIATION
• Facilitates patient to have access to services and
equipment identified in the care plan
• C...
4. PSYCHO SOCIAL
SUPPORT
• Good relationships fostered by
regular contact make patients
more confident and increase
well b...
5. MONITORING AND REVIEW
• A well written care plan is the basis for review
• Frequency of monitoring depends on individua...
TELE HEALTH SERVICE
6. CASE CLOSURE
Four possible methods of discharge from case
management programme
• Death
• Self discharge
• Decision by t...
FACTORS DETERMINING EFFECTIVE
CASE MANAGEMENT
The key enabling factors include
Role and skills of case manager
• Assigned...
Programme design
• Targeting and eligibility
• Manageable case load
• Single point of care
• Effective use of data and co...
Factors within the wider system
• Shared vision and objectives
• Close links between health and social care
• Aligned fin...
ROLES AND SKILLS
• ASSIGNED ACCOUNTABILITY
Successful case management requires an individual
or team with oversight of ,...
• ROLE AND REMIT
Clarity around the roles, responsibilities and
boundaries of team members facilitate case
management
Co...
• SKILLS AND SUPPORT
Key skills that case managers need include:
Inter personal skills
Problem solving skills
Negotiati...
• BUILDING RELATIONSHIPS
Case managers and their patients
Case managers and GPs
Case managers and hospital staff
PROGRAMME DESIGN
• TARGETING AND ELIGIBILITY
Case finding helps in finding target cases(most at risk
and can benefit mos...
• MANAGEABLE CASE LOAD
Multiple roles include direct
patient care, administrative tasks,
attending or delivering training...
Number of patients manageable in a case
load is influenced by:
• Nature of patient’s conditions
• Patients socio-demograph...
• SINGLE POINT OF ACCESS/SINGLE
ASSESSMENT
Information sharing protocols can help to facilitate
assessment process
Singl...
• CONTINUITY OF CARE
Case manager should retain oversight over the
entirety of individual’s situation over time.
It give...
•EFFECTIVE USE OF DATAAND
COMMUNICATION PROCESSES
Case management depends on exchange of
information between partners wor...
FACTORS WITHIN THE WIDER
SYSTEM
• SHARED VISION AND OBJECTIVES
Case management need to develop clear goals and
objective...
• CLOSE LINKS BETWEEN HEALTH AND
SOCIAL CARE
People with complex needs nearly always require
support from both health and...
•ALIGNED FINANCIAL FLOWS AND
INCENTIVES
Different funding options have been used to support
case management
 Pooled budge...
STAKEHOLDER ENGAGEMENT
1. Case management needs
trust, support and
enthusiasm of local
stakeholders
2. engage key professi...
•PROVISION OF SERVICES WITH IN THE
COMMUNITY
• Case managers need to draw on a range of
resources and services in the comm...
ROLE OF NURSE AS CASE MANAGER
• Advocacy and education
• Clinical care coordination/facilitation
• Continuity/ transition ...
CRITICAL
PATHWAYS OF
CARE
DEFINITION
• A care pathway is anticipated care placed in an
appropriate time frame, written and agreed by a multi
discipl...
CPC TEAM INCLUDES
• Nurse case manager
• Clinical nurse specialist
• Social worker
• Psychiatrist
• Psychologist
• Dietici...
HOW CPC IS CARRIED OUT
• The team decides what categories of care are to be
performed, by what date and whom
• Each member...
• If variations occur at any time in any of the categories
of care, rationale must be documented in the progress
notes
• T...
• Within 24 hours, the interdisciplinary team meets to
decide on other categories of care
• Completion of the CPC, and mak...
• CPCs can be standardised because they are intended
to be used with uncomplicated cases
• A CPC can be viewed as protocol...
CHARACTERISTICS OF CPC
• Pathway is a projection of the client’s entire length of
treatment
• Includes detailing of interd...
VARIANCES
DEFINITION
A variance is defined as an unexpected client response
that “falls off” the pathway, requiring separa...
CAUSES OF PATHWAY VARIANCE
• Client or family
• Caregivers
• Hospital
• Community
• Payer(including insurance companies, h...
BENEFITS OF CPC
• Support the introduction of evidence based medicine
and use of clinical guidelines
• Support clinical ef...
• Help to improve clinical outcomes
• Ensure quality of care and provide a means of
continuous quality improvement
• Help ...
DEMERITS OF CPC
• Adaptability-on complicated case CPC becomes large
and detailed, cumbersome and ineffective
• Crash acti...
CONCLUSION
Critical pathways are tools to achieve patient or
programme outcomes.
It is the process of team collaboration...
THANKYOU........
Nursing case management and critical pathways of care
Nursing case management and critical pathways of care
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Nursing case management and critical pathways of care

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Nursing case management and critical pathways of care

  1. 1. NURSING CASE MANAGEMENT AND CRITICAL PATHWAYS OF CARE PRESENTED BY MS JIYA G PANTHANALIL IST YEAR MSC NURSING NIMHANS, BANGALORE
  2. 2. INTRODUCTION  Concept of case management evolved with advent of diagnosis related groups (DRGs) and shorter hospital stays  Innovative model of care delivery that can result in improved client care  Clients are assigned a manager who negotiates with multiple providers to obtain diverse services  Decreases fragmentation of care
  3. 3. DEFINITION • Managed care refers to a strategy employed by purchasers of health care services who make determinations about various types of services in order to maintain quality and control costs
  4. 4. Managed care exists in many settings: • Insurance –based programs • Employer –based medical providerships • Social service programs • The public health sector
  5. 5. FEATURES OF CASE MANAGEMENT • Method used to achieve managed care • Actual coordination of services with in the fragmented health care system • Strives to help at-risk clients • Controls health care costs to consumer and third party payers
  6. 6. COMPONENTS Case finding Assessment Care planning Care co-ordination
  7. 7. CASE FINDING • Systematic method • identify individuals who are at risk of hospital admissions • Aims at preventing unplanned admissions • Patients who are currently experiencing multiple emergency admissions have fewer emergency admissions in future- ‘regression to the mean’ • Identify the patient before they deteriorate
  8. 8. ASSESSMENT • Assessment of current level of ability • Physical and social care needs • Assessment is not restricted only to health needs
  9. 9. CARE PLANNING Care plan address individuals’ full range of needs including • Health, personal, social, economic, educational, mental health, ethnic, and cultural background and circumstances Care plan provides structure to individual’s care and ensure that goals of different services are aligned with each other
  10. 10. Care plan enables case manager to • Make referrals to various services • Co-ordinate all the different services he/she should liaise with • Ensure that referrals have been picked up and acted on • Monitor whether individual has made any progress
  11. 11. • Care plan should be viewed as a live document • Review the individual’s health and social care needs and revise the care plan accordingly • Care plan is in a constant state of change • It depends on individual’s condition and how much progress has been made • It is an ongoing process that structures and facilitates effective delivery of care over time
  12. 12. CARE CO-ORDINATION Reduce duplications of health care Avoid gaps and reduce health and social care service costs Improved disease management Faster discharge from hospital
  13. 13. COMMON ACTIVITIES IN CARE CO-ORDINATION 1. MEDICATION MANAGEMENT -Ensure that individual’s medication regimen is appropriate and upto date -adherence of treatment regimen and monitor for adverse effects -communicate with individual patient, general practice staff, specialists, pharmacists
  14. 14. 2. SELF CARE SUPPORT Providing general health education and advice Providing health education and advice specific to individual’s long term conditions Coaching about most appropriate service to contact related to health or when a crisis occurs
  15. 15. 3. ADVOCACY AND NEGOTIATION • Facilitates patient to have access to services and equipment identified in the care plan • Case manager directly negotiate with service providers • Speed up the process of obtaining medication, equipment or home care services
  16. 16. 4. PSYCHO SOCIAL SUPPORT • Good relationships fostered by regular contact make patients more confident and increase well being • Psychological support is a key strategy in supporting self care • Helps to identify and support individual to behavioural change and facilitate changes in future goals
  17. 17. 5. MONITORING AND REVIEW • A well written care plan is the basis for review • Frequency of monitoring depends on individual’s level of need • Monitoring can take place Daily Weekly Monthly Directly in individual’s home Through remote monitoring(by telephone, telehealth device)
  18. 18. TELE HEALTH SERVICE
  19. 19. 6. CASE CLOSURE Four possible methods of discharge from case management programme • Death • Self discharge • Decision by the case manager and multidisciplinary team • patient’s risk of hospital admission identified by a risk prediction tool falls below a certain level as determined by case management programme
  20. 20. FACTORS DETERMINING EFFECTIVE CASE MANAGEMENT The key enabling factors include Role and skills of case manager • Assigned accountability • Role and remit • Skills and support • Building relationships
  21. 21. Programme design • Targeting and eligibility • Manageable case load • Single point of care • Effective use of data and communication processes
  22. 22. Factors within the wider system • Shared vision and objectives • Close links between health and social care • Aligned financial flows and incentives • Stakeholder engagement • Provision of services in the community
  23. 23. ROLES AND SKILLS • ASSIGNED ACCOUNTABILITY Successful case management requires an individual or team with oversight of , and is accountable for the whole processes Risk of fragmented care when accountability is not clearly assigned
  24. 24. • ROLE AND REMIT Clarity around the roles, responsibilities and boundaries of team members facilitate case management Confusion over roles can lead to tension Perceived seniority of one service over another, and rivalry between different professionals can cause problem
  25. 25. • SKILLS AND SUPPORT Key skills that case managers need include: Inter personal skills Problem solving skills Negotiation and brokerage skill Prescribing qualifications Training
  26. 26. • BUILDING RELATIONSHIPS Case managers and their patients Case managers and GPs Case managers and hospital staff
  27. 27. PROGRAMME DESIGN • TARGETING AND ELIGIBILITY Case finding helps in finding target cases(most at risk and can benefit most) Where targeting is not accurate, programme will not be cost effective Programme should set out clear criteria for discharge
  28. 28. • MANAGEABLE CASE LOAD Multiple roles include direct patient care, administrative tasks, attending or delivering training sessions and attending meetings It can affect case managers’ capacity to provide care for all patients
  29. 29. Number of patients manageable in a case load is influenced by: • Nature of patient’s conditions • Patients socio-demographic profiles • Patient’s circumstances • patient’s geographical area • patient’s individual characteristics • Time needed for non clinical activities
  30. 30. • SINGLE POINT OF ACCESS/SINGLE ASSESSMENT Information sharing protocols can help to facilitate assessment process Single Assessment Process (SAP) introduced in 2001 aimed to reduce duplication in health and social care SAP was designed to standardise assessment across different agencies and settings to raise overall standard of care and uniformity
  31. 31. • CONTINUITY OF CARE Case manager should retain oversight over the entirety of individual’s situation over time. It gives a valuable sense of continuity for the patient
  32. 32. •EFFECTIVE USE OF DATAAND COMMUNICATION PROCESSES Case management depends on exchange of information between partners working in different teams All information is streamed centrally through case manager Constant communication and timely information exchange with multidisciplinary team is vital Critically patient has a single point of contact to whom they can address any queries or concerns
  33. 33. FACTORS WITHIN THE WIDER SYSTEM • SHARED VISION AND OBJECTIVES Case management need to develop clear goals and objectives It should be understood by all partners Sense of shared responsibility and collaborative approach facilitate better co-ordination of care Where different partners or elements of system do not share same vision, care co-ordination is difficult
  34. 34. • CLOSE LINKS BETWEEN HEALTH AND SOCIAL CARE People with complex needs nearly always require support from both health and social care services Social care is particularly important for patients in rehabilitation and re- ablement phases
  35. 35. •ALIGNED FINANCIAL FLOWS AND INCENTIVES Different funding options have been used to support case management  Pooled budgets: eg. Castlefields example  Capitation: Fixed sum of money per patient can be used for a package of care services, where case management team takes responsibility for a patient’s care over time
  36. 36. STAKEHOLDER ENGAGEMENT 1. Case management needs trust, support and enthusiasm of local stakeholders 2. engage key professionals and teams in the case management
  37. 37. •PROVISION OF SERVICES WITH IN THE COMMUNITY • Case managers need to draw on a range of resources and services in the community • It helps patient to receive care at home • Community resources must be effectively commissioned and case managers should know what is available and how to access it
  38. 38. ROLE OF NURSE AS CASE MANAGER • Advocacy and education • Clinical care coordination/facilitation • Continuity/ transition management • Performance and outcomes management • Psychosocial management • Research and practice development • Utilisation review • Quality management • Discharge planner
  39. 39. CRITICAL PATHWAYS OF CARE
  40. 40. DEFINITION • A care pathway is anticipated care placed in an appropriate time frame, written and agreed by a multi disciplinary team-Welsh National Leadership and Innovation Agency for Health care(2005) • A critical pathway is a type of abbreviated plan of care that provides outcome-based guidelines for goal achievement within a designated length of stay.
  41. 41. CPC TEAM INCLUDES • Nurse case manager • Clinical nurse specialist • Social worker • Psychiatrist • Psychologist • Dietician • Occupational therapist • Chaplain and others
  42. 42. HOW CPC IS CARRIED OUT • The team decides what categories of care are to be performed, by what date and whom • Each member of the team is then expected to carry out his or her functions according to the time line designated on the CPC • The nurse as case manager is ultimately responsible for ensuring that each day of assignments is carried out
  43. 43. • If variations occur at any time in any of the categories of care, rationale must be documented in the progress notes • The nurse contacts psychiatrists to inform him or her of the admission • The psychiatrist performs additional assessments to determine if other consultations are required
  44. 44. • Within 24 hours, the interdisciplinary team meets to decide on other categories of care • Completion of the CPC, and make individual care assignments from the CPC • Each member of the team stays in contact with the nurse case manger regarding individual assignments. • Ideally team meetings are held daily or every other day
  45. 45. • CPCs can be standardised because they are intended to be used with uncomplicated cases • A CPC can be viewed as protocol for various clients with problems for which a designated outcome can be predicted
  46. 46. CHARACTERISTICS OF CPC • Pathway is a projection of the client’s entire length of treatment • Includes detailing of interdisciplinary intervention or processes and client outcomes each day from admission to discharge • Pathway may be extended to include transfer to home care or another treatment facility
  47. 47. VARIANCES DEFINITION A variance is defined as an unexpected client response that “falls off” the pathway, requiring separate documentation and further investigation by the interdisciplinary team.
  48. 48. CAUSES OF PATHWAY VARIANCE • Client or family • Caregivers • Hospital • Community • Payer(including insurance companies, health maintenance organisations, or managed care organisations)
  49. 49. BENEFITS OF CPC • Support the introduction of evidence based medicine and use of clinical guidelines • Support clinical effectiveness, risk management and clinical audit • Improve multidisciplinary communication, team work and care planning • Can support continuity and co-ordination of care • Provide explicit and well defined standards of care
  50. 50. • Help to improve clinical outcomes • Ensure quality of care and provide a means of continuous quality improvement • Help to improve communication between different care sectors • Disseminate accepted standards of care • Provide baseline for future initiative • Reduce costs by shortening hospital stays
  51. 51. DEMERITS OF CPC • Adaptability-on complicated case CPC becomes large and detailed, cumbersome and ineffective • Crash action-changes from scheduled plan in a timeline, crash action involving reprioritizing each step • Resource allocation-when resource don’t match CPC map, CPC begins to unravel
  52. 52. CONCLUSION Critical pathways are tools to achieve patient or programme outcomes. It is the process of team collaboration that ultimately produce quality outcome Case management is critical to the success of pathways By guiding pathway implementation and variance analysis, case manger can assure value to patient through out the continuum
  53. 53. THANKYOU........

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