Nurse Case Management: The New Model

1. Nurse Case Management: The New Model Brought to you by the Case Management Team of SLMV Presentation built by Courtney Willis, RN BSN

2. Overview • Nurse Case Managers: What and Why? • Controlling Costs and Interqual. • How you can help. • Workplace conflict and the conflict process • Conflict resolution • Teamwork • Feedback • Acknowledging patient/family complaints

3. What is a Nurse Case Manager???

4. What is a Nurse Case Manager? • CM are nurses that coordinate care, maintain quality, and contain costs while focusing on the outcomes of care. • CM are client focused and outcome-oriented.

5. Nurse Case Managers • Nurse Case Managers have been involved in mental health and social services for years, mostly in outpatient settings. • Nurse Case Managers role in the acute setting is evolving.

6. St. Luke’s job description • Provides clinically-based CM to support the delivery of effective and efficient patient care. • Has overall accountability for the UM and discharge plan for pts within the assigned caseload. • Collaberates with members of the health care team to identify appropriate utilization of resources and to ensure reimbursement.

7. St. Luke’s job description (cont) • Utilizes criteria to confirm medical necessity for admission and continued stay. • With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources.

8. Nurse Case Managers • Greater efforts are being made to improve the quality of patient care by focusing on patient outcomes. • The plan of care is initiated on admission and developed throughout the course of the patient’s hospitalization.

9. Nurse Case Managers • CM use clinical experience to assess the patient’s and family’s current status and in identifying their actual and potential problems. • CM depend on their clinical knowledge and previous experiences when implementing approaches to patients care to help resolve these problems.

10. Nurse Case Managers • CM clinical skills enable them to assess the patients as biopsychosocial beings and to plan the treatments to meet the patients’ needs as a whole system and not just the disease.

11. NCM use concept maps to make plans of care.

12. Why Case Managers? • Traditional nursing has been challenged by a multitude of issues posed by the evolving health care systems, settings, and professional practice.

13. Why Case Managers? • “Prospective payment, which is now considered the economic driver across acute, community, and long-term care settings; cont cutbacks in Medicare reimbursements, along with numerous shifts in the configurations of managed care; and demographic changes in work force composition have compelled providers of health care services to engage

14. Why Case Managers (cont) in the restructuring and innovative rethinking of priorities related to the delivery and management of patient care.” Nursing Case Management. From Essentials to Advanced Practice Applications.

15. What does this mean????? There is a new focus on different approaches of care delivery which has promoted those in health services settings to look at alternative delivery systems as a means of improving patient outcomes and controlling costs.

16. Controlling Costs • As Healthcare reform continues, Medicare is only paying hospitals for meeting standards of care. • To meet these standards of care, a new system wide nurse case management model has been initiated. • We evaluate the care being given to the patients against Interqual criteria.

17. Interqual • Interqual is a collection of research based standards of care based on diagnosis, symptoms, comorbidities and medical interventions. • If we do not follow these guidelines, or document a contraindication to these guidelines, we do not get paid for the services we are providing.

18. For Reimbursement • Every chart has to have a status order: - Outpatient Procedure - Outpatient Observation - Inpatient These are the only three only recognized admission orders.

19. How can you help? • When you are reviewing a chart or noting orders, please look for a status order. • “Admit to 2N, 3N” or “Admit” will not work.

20. How you can help • If the status order is missing, please enter a UM consult of if you are in contact with the MD, please ask him to clarify which status he would like the patient in. • If you have not been trained in Interqual, please do not recommend a status.

21. How Can You Help? • Be sure to document all assessments, even if they are normal. • On appropriate neuro patients (THI, TIA, CVA, Bleeds, decreased LOC etc.), encourage bedside RN to complete and chart q4 hour neuro checks. • Document time spent on complicated care (ie. Complex dressing changes) and declining status. • Rapid Response / ICU transfer – please give details in notes as to why.

22. Remember… If it was not charted, it was not done!!

23. Team Members:

24. Team Approach • Seek and provide peer consultation when a patient is experiencing significant deviation from the plan of care. • Consistently attend care rounds and actively participate in them. • Maintain an effective working relationship with physicians in managing the care of their patients. • Act as a resource to the team regarding insurance benefits, managed care processes, and utilization issues.

25. Workplace Conflict • Identify the problem. • Communicate with the appropriate people about the problem. • Develop a set of possible solutions. • Decide on one of the options. • Carry out the action required. • Monitor to guarantee the action is taken. • Evaluate the effectiveness of your decision-making process. Modified from Nursing Case Management. From Essentials to Advanced Practice Applications. (2005).

26. The Conflict Process The ability to resolve conflicts productively depends on understanding the conflict process and developing creative ways to deal with conflict.

27. The Conflict Process

28. Workplace Conflict • If conflict with patient/family, we switch CM. We want out patients to have the best care possible. • We are part of the quality assurance department. If the issue needs resolution that we are unable to get ourselves, we involve management who investigates the situation and assists in resolution.

29. Conflict Resolution • Case Management has it’s own shared governance. If there is an ongoing issue, it is discussed with all of the CM department at our monthly shared governance meetings, which involves management.

30. Conflict Resolution is dependent on… • Quality of Decisions 1. How creative are the resulting plans? 2. How practical and realistic are they? 3. How well were intended goals achieved? 4. What surprising results were achieved? Modified from Hurst, J., & Kinney, M. (1989). Empowering self and others. Toledo, OH: University of Toledo

31. Conflict Resolution is dependent on (cont)… II. Quality of relationships 1. How much understanding has been created. 2. How willing are people to work together? 3. How much mutual respect, empathy, concern, and cooperation has been generated? Modified from Hurst, J., & Kinney, M. (1989). Empowering self and others. Toledo, OH: University of Toledo.

32. Personality styles affecting teamwork • Obviously there are several types of personalities in healthcare. • The best way I have found to work with all of the different personalities is: keep the goal of the job in mind and always keep it professional. If unable to keep situation professional then you need to go through the chain of command.

33. Personality Styles affect working in teams • Staff need to know and understand their own personality traits- what strength/weaknesses do they have? • Understand and value individual styles.

34. Appropriate feedback to enhance teamwork: • Planning (includes assessment) • Organizing • Implementing • Evaluating • Feedback Feedback functions in conjunction with the first four of the previous list to assess the ongoing status of the change process and movement toward desired outcome.

35. Communication • Maintain confidentiality in matters relating to patient/family/coworkers. • Provide information to patient and families to reduce anxiety and convey an attitude of acceptance, sensitivity, and caring. • Communicate with peers about clinical priorities for care.

36. Giving and receiving appropriate feedback • Don’t give or take it personally. • Should be used as a constructive tool for learning and bettering self and situations. • Pick your battles.

37. Acknowledging patient/family complaints. • Listen to the complaint. • Understand and clarify the situation. • Respond to the complaint (use colleagues for support). • Reassess the situation- is the conflict resolved? • Is there need for a change in program or involve shared governance?

38. You survived all 38 slides!!! Question and Answer time.