Nursing case management and critical pathways of care involve assigning a case manager to coordinate a client's care across multiple providers according to a planned timeline. A case manager assesses clients' needs, develops care plans, and ensures services are delivered as planned. Key factors in effective case management include well-defined roles for the case manager, manageable caseloads, and strong communication between healthcare organizations. Critical pathways outline anticipated care for specific conditions over a set period, with daily team meetings to monitor progress and adjust plans if needed. They aim to standardize high-quality care while controlling costs.

1. NURSING CASE MANAGEMENT
& CRITICAL PATHWAYS OF
CARE
PRESENTED BY:-
SUSHMA
M.SC. (Nsg)1ST
YEAR

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
• Decrease fragmentation of care

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. Managed care exists in many
settings:
• Insurance –based programs
• Employer –based medical providerships
• Social service programs
• The public health sector

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. COMPONENTS
• Case finding
• Assessment
• Care planning
• Care co-ordination

7. CASE FINDING
• Systematic method
• dentify 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. ASSESSMENT
• Assessment of current level of ability
• Physical and social care needs
• Assessment is not restricted only to health
needs

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. 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. Contd…
• 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. 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. • 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. 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. 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. 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. 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. 6. CASE CLOSURETELE HEALTH
SERVICE
• 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

19. FACTORS DETERMINING
EFFECTIVE CASE
MANAGEMENT
• The key enabling factors include
Role and skills of case manager
o Assigned accountability
o Role and remit
o Skills and support
o Building relationships

20. • Programme design
Targeting and eligibility
 Manageable case load
 Single point of care
 Effective use of data and communication
processes

21. 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

22. 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

23. 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

24. SKILLS AND SUPPORT
• Key skills that case managers need
include:
Inter personal skills
Problem solving skills
Negotiation and brokerage skill
Prescribing qualifications
Training

25. BUILDING RELATIONSHIPS
• Case managers and their patients
• Case managers and GPs
• Case managers and hospital staff

26. 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

27. 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

28. 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

29. 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

30. 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

31. EFFECTIVE USE OF DATA AND
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

32. 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

33. 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

34. 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

35. STAKEHOLDER ENGAGEMENT
1. Case management needs trust, support
and enthusiasm of local stakeholders
2. .engage key professionals and teams in
the case management

36. 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

37. 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
• Utilization review
• Quality management
• Discharge planner

38. CRITICAL PATHWAYS OF CARE

39. 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

40. CPC TEAM INCLUDES
• Nurse case manager
• Clinical nurse specialist
• Social worker
• Psychiatrist
• Psychologist
• Dietician
• Occupational therapist
• Chaplain and others

41. 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

42. Contd..
• 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

43. Contd..
• 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

44. Contd..
• 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

45. 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

46. 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.

47. CAUSES OF PATHWAY
VARIANCE
• Client or family
• Caregivers
• Hospital
• Community
• Payer(including insurance companies,
health maintenance organisations, or
managed care organisations)

48. 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

49. Contd..
• 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

50. 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

51. 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. THANK
YOU!