The position of nurse case managers can be a rewarding but challenging career, as these managers play a vital role in a patient's care. In A Guide for Nurse Case Managers, author Charlotte Cox provides an insightful guide to this evolving field of medicine. Geared for those working in hospital settings, clinics, and health plan offices, this helpful reference text provides guidelines, tips, and tools for becoming a successful nurse case manager. With more than thirty years of health care experience, Cox provides a detailed overview of this important nursing position that works to usher a patient through the health care system. A Guide for Nurse Case Managers • defines the case manager role; • provides an understanding of the basics of utilization and case management; • gives an overview of Medicare and Medicaid procedures; • discusses the care planning process; • shows how to structure a community resource base. Whether you are a new case manager, a student, or a seasoned nurse needing a refresher about job basics, A Guide for Nurse Case Managers will help to shape your practice, provide valuable tips and reference tools, and help you with proven organizational ideas to succeed in the career.
A Guide for Nurse Case Managers
By Charlotte CoxiUniverse, Inc.
Copyright © 2010 Charlotte Cox
All right reserved.ISBN: 978-1-4502-3855-7Contents
Disclaimer................................................................................viiPreface-Note to the Reader................................................................ixAcknowledgments...........................................................................xiiiChapter 1: The Case Manager Role..........................................................1Definition of Case Management.............................................................1Nurse Case Manager Functions..............................................................2Brief Overview of the Case Manager Utilization of the Nursing Process.....................2Chapter 2: Care Planning Processes........................................................5Care Planning Guidelines..................................................................5Patient Needs Assessment Guide............................................................8Patient Prescription Assessment...........................................................12Chapter 3: Balancing Utilization Management Practice......................................19Precertification Process..................................................................20Insurance Review..........................................................................21Denial Process............................................................................22Length-of-Stay Issues.....................................................................25Hospital Patient Status...................................................................27Chapter 4: Medicare/Medicaid..............................................................31Medicare Basics...........................................................................31Medicaid Basics...........................................................................33Chapter 5: Tapping into Community Resources...............................................35Develop a Community Database..............................................................35Chapter 6: Quick Reference Tools..........................................................41Tool #1: Medicare Information Tool-2010...................................................43Tool #2: Medicaid Information Tool-2010...................................................44Tool #3: Case Management Patient Needs Assessment Guide...................................45Tool #4: Patient Assessment Form..........................................................46Tool #5: Resource List....................................................................48Tool #6: Clinical Review Format...........................................................49Tool #7: Payer Basics.....................................................................51Tool #8: Patient Prescription Assistance Guide............................................53Tool #9: Patient Prescription Assistance Form.............................................55Tool #10: Consent for Case Management Services............................................57Chapter 7: Conclusion-Ready, Set, Go......................................................59About the Author..........................................................................65Definitions and Terms Related to Utilization and Case Management..........................67References................................................................................73
Chapter One
The Case Manager Role
Definition of Case Management
Let's begin by defining case management. The Commission for Case Manager Certification (CCM) states, "Case Management is a collaborative process that accesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes."
You're hired as nurse case manager. As you begin this new career in nursing, questions surface about the role. Beginning with the very first day of orientation, terms, such as utilization, discharge planning, and insurance contracts, heighten your interest. This verbiage is only the start of a new language of nursing. You also hear discussions regarding length-of-stay issues, variance tracking reports, and insurance authorizations, as the list continues.
It isn't long before you figure out that case management is unlike any other nursing field you've experienced. Wow! This is such a new avenue of nursing for you and many others.
Nurse Case Manager Functions
The nurse case manager is the one person who guides the patient through the health system. Service areas include hospital case management, worker's compensation, health plans, disease management, outpatient care, military programs, and agencies providing services to the homebound patient. Many avenues exist, allowing the case manager to assess and plan for life-care changes for any age group.
Depending on the facility program, social workers and case managers may perform similar duties in providing case management. The nurse case managers educate the patient with vital information regarding their disease process and expected outcomes, while coordinating services as identified in patient/ family interviewing.
Brief Overview of the Case Manager Utilization of the Nursing Process
A thorough assessment reveals actual or potential patient needs for which the nurse case manager can then begin planning and coordinating services as applicable. Handy assessment tools used during the interviewing process will help the case manager organize caseloads. Once all parties agree on the needs identified and the plan outlined to meet the needs, the case manager will then coordinate and implement the individualized case plan.
This nursing process requires excellent communication across the continuum of care among health-care providers. Don't forget to include the immediate family members and significant others, who play an important role in helping our patients meet their care needs. As a patient advocate, the nurse case manager seeks quality, cost-effective resources in order to meet the identified care needs.
Just remember to follow the Health Insurance Portability and Accountability Act (HIPAA) guidelines during initial interviews in discussing care needs and discharge/home care plans. This act, which was passed in 1996, allows the federal government to regulate certain aspects of the health insurance industry. It also addresses the rights of employees, patient privacy/confidentiality standards, coding/transactions, and oversight of insured and noninsured clients.
Once the case plan is implemented, the nurse case manager follows up to ensure the patient care needs are indeed met. This process includes coordinating insurance updates and selected agency/facility input. An evaluation process is vital to ensure the intended outcome is successful.
If the plan fails or is inadequate to fully meet the identified patient needs, the nurse case manager starts over. The process begins with reassessment followed by planning, implementation, and evaluation. Don't fret; many patient care plans change in midstream or as needs change in cases involving long-term medical disease processes. View this curvature as a challenge to sharpen your skills within the field of case management.
Patients and families are grateful that the nurse case manager is coordinating the hospital discharge plan or home plan. She or he is connecting them with community resources necessary to ensure care needs are met in a timely manner. Using proven methods to secure the best possible services for your clients enhances your credibility within the profession. Strive toward providing exceptional service and gaining client trust, and others will want to follow in your steps.
Tip-Just remember to follow the Health Insurance Portability and Accountability Act guidelines during initial interviews and when discussing care needs and discharge/home care plans.
Let's begin to delve into the tools necessary for your success within the field of case management. The following is only meant to help guide your practice and should be community tailored to address the clients served. What may seem ideal for one part of the country, in reality, may not be suited for your neck of the woods.
Individual care planning involves researching the community resources available. Take a few moments to consider the various types (homeless, low-income, military, insured, etc.) of clients served. A wise nurse case manager does the preparatory work necessary to best serve those patients and families needing guidance and care planning.
Chapter Two
Care Planning Processes
Care Planning Guidelines
Most health-care facilities utilize practice guidelines in providing quality care to their clients served. These practice guidelines help to guide the health team with the management and delivery of care.
The primary focus is always the patient. As with facility processes implemented, care planning processes are a focus in nurse case management. Hospital departments have unique guidelines and policies outlined in order for employees to understand the expectations within their work environment. Likewise, utilization and case management departments follow a plan that all case managers and secretarial staff must understand in order to comply.
Any process should be looked at from various angles to determine the most appropriate path to achievement of the desired outcomes. Examining outcomes helps us measure the delivery and quality of care provided, thus promoting patient safety as a number-one priority. Sound familiar?
Tip-Specific short-term and long-term goals are outlined by the nurse case manager in order to help the patient achieve these goals before dismissal from a hospital setting.
In addition, familiar terms, such as nursing care plans or clinical pathways, may pop into your head. Nursing of the past, present, and future will always be guided in any clinical practice area. Some form of a care plan will guide the health-care team in providing holistic care to the patients. No matter the field of nursing practiced, there is a standard of care to uphold, a professional standard of conduct expected, and a desire to continue the Florence Nightingale basic traditional art and science of nursing in all of us.
Care plans focus on the documentation of care provided in a narrative form. The nurse case manager outlines specific short-term and long-term goals to help the patient achieve these goals before being dismissed to go home from a hospital setting. Short-term goals may include specifics as to stabilization of a medical crisis, a normalization of lab values, or a focus in resolving the acute illness.
We see the long-term goals while helping patients to a achieve a maximal level in quality of life, returning a chronic disease process to baseline, focusing on preventative measures, and empowering clients to become managers of their own health. Did I say to empower the client? Yes, indeed!
Patients and families in today's world of communicative avenues thrive on obtaining the knowledge and the best of every available health-care technology to overcome acute, chronic, and debilitating diseases. Armed with information and literature from the Internet, the media, and social contacts, clients end up becoming their own advocates in promoting their agendas for maintaining quality health care. As we in health care are increasingly aware, the "I want" or "I need" may not necessarily be the appropriate standard of care for the illness or disease diagnosed.
It takes a wise and knowledgeable medical provider to discern the best practice and path to pursue with the client's treatment plan. At times, honesty is the best policy. Unfortunately, some clients don't want to hear a proposed plan that doesn't meet with their satisfaction or agenda.
Tip-Just remember to follow these basic steps (our nursing process), which include assessing, identifying needs, determining objectives/goals, developing an action plan, implementing/coordinating the plan, and evaluating the plan.
In some cases, the clients will pursue another provider for a second opinion, a third opinion, and so on until they achieve their own goals. Don't take it personally, because it is not. Patients have the right to follow what they feel they must do in order to see the other options available. Unfortunately, some pursue what they want regardless of what is recommended or the costs involved.
The following practice guidelines are exactly what any nurse case manager needs in order to function effectively when working with patients and families. How do you get involved? Many avenues exist for case management services.
Your referrals may come from a physician's office, a home health nurse, an insurance carrier, hospital staff, the emergency center, or urgent care, or the patient and family members may enlist your services. Depending on your practice setting and the referral process in your agency or facility, the nurse case manager is available to assist and coordinate any services related to patient care.
Just remember to follow these basic steps (our nursing process):
Assess Identify needs Determine objectives/goals Develop an action plan Implement/coordinate plan Evaluate plan
Before you know it, the nursing case management process becomes second nature in your daily interactions. The practice guidelines are broken into basic steps for easy reference (refer to Quick Reference Tool #3, Case Management Patient Needs Assessment Guide).
Patient Needs Assessment Guide
We begin with reviewing the process of the patient needs assessment guide. As mentioned earlier, a thorough patient assessment is crucial to the identification of any real or actual care needs. The initial patient assessment is the in-depth data collection process to identify those needs in order to develop a comprehensive nursing case management plan (refer to Quick Reference Tool #4, Patient Needs Assessment Tool).
Assessed items should include the patient's demographics, phone contact information, employer contact information, insurance plan, medical diagnosis and pertinent medical history, specific self-care/assistance requirements, any current agency support/services, and stated perceived patient/family concerns. Remember to block at least thirty to sixty minutes to complete this initial information-gathering process. The assessment tool can be easily filed for future reference.
Once the initial assessment is completed, the case manager moves on to the next step, which is to identify any real or potential needs. You've gathered important information with your patient over the past hour and have likely put your contact at ease. Now is the time to focus on what exactly the perceived problem or need is. After all, you need to clarify why you're involved with the case. Allow the patient to verbalize any concerns.
You may hear problems voiced, such as a need for caregiver assistance in the home, equipment needs, insurance questions regarding coverage of services, inability to maintain therapy due to the costs of medications, guardianship issues, family conflict, and social issues. These social issues may involve living conditions, homeless concerns, paying for rent/utilities, etc.
Be prepared to direct the conversation to specific concerns, as some may trail off on unrelated issues. Specific concerns voiced help to further identify the need for case management services. Or, if not preempted, you may find yourself in the middle of a family squabble that you can't do anything to resolve. Just remember to politely listen and be supportive. List the concern objectively on your assessment form.
The second step is to correctly identify the patient need as perceived by the patient. Review the compiled data, and note the perceived concern identified above. Case management services will focus on the identified patient need you list. At this time, you may notice the perceived concern or need is different or could possibly be the same as the one you identified.
For instance, patient Joe Johns may seem to need home health care or home equipment based on the information provided. Yet, after conferring with Joe, you also identify he lives alone and is unable to meet his self-care needs even with enlisted agency assistance. Hence, Joe needs twenty-four-hour care, and a home plan may not be a realistic option at this time.
Once you and your client agree on the problem or a need that requires your services, outline the objectives and goals for the process. The case manager will strive toward accomplishment of these goals. Include short-term or long-term goals to assist your clients to successful case management. State the goals, and have the patient also restate his or her understanding of the objectives that you will strive to achieve on his or her behalf.
In the fourth step, the case manager develops a plan of action. This process is one of organizing, securing, and integrating the necessary resources to meet the identified objectives and goals outlined in step four. The case plan may involve assistance in placing our client (Joe) within a residential, skilled, or nursing home facility in order to meet his current needs. With other cases, this may involve helping a client obtain necessary prescriptions or home health care, resolve transportation issues, or arrange home oxygen.
Whatever the identified need, the case manager documents the plan of action to meet the stated objectives/goals. Before proceeding to step five, collaborate with your patient to secure his or her understanding of the proposed plan. Include family members as applicable.
Coordinating services requires a case manager's expertise when implementing the plan necessary to meet the patient's identified needs. While executing the agreed plan of action, the case manager puts the pieces of the plan into motion. To successfully implement the stated plan, communication to all involved parties is once again vital.
Explain to your client the agencies available, and provide lists where applicable in every situation. Making the choice of facility or agency allows the parties to become actively involved in their own care planning. Also, the law mandates the patient's choice of agency.
Notify the agency or party who will contract or accept the patient's outlined plan to secure their services. Coordinate the onset of services and the delivery time or date, and keep the patient informed of all action plans. Follow up with a phone call to family members as indicated with the arrangement of services.
Remember when communicating with agencies to obtain contact names and fax numbers and give your own fax/phone number to ensure coordination of services. Also provide your client with a contact number so that he or she may reach you after hours with any concern or question that may arise. Communication is the cornerstone of implementing your plan of care to success.
Lastly, the sixth step is the case manager's evaluation. How effective were you as the case manager in reaching the desired objectives and goals? A case manager or any leader will tell you to always have an evaluation process in place to measure your success.
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Excerpted from A Guide for Nurse Case Managersby Charlotte Cox Copyright © 2010 by Charlotte Cox. Excerpted by permission.
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