These phases are not linear, in that we do not complete a phase and check it off our list as complete. Phases may be revisited as needed until the desired outcome is reached. For example, after following up with a patient, new problems may be identified. At this point you would return to the planning phase.
The objective of the screening phase is to determine if the patient would benefit from Case Management Services. During the screening phase, information is reviewed to decide the patients appropriateness for Case Management. The information reviewed may include claims information, utilization of healthcare services, current health status and health history, among others. Patients are usually screened due to:
The Stratifying Risk phase determines the appropriate level of intervention by classifying the patient as being at low, or high risk. A health risk assessment and biomedical screening are done based on the patients risk factors. In some organizations stratification may take place prior to assessing by an automated system. In this case the Case Manager would review the information generated and contact the patient if appropriate.
CCMC defines planning as, “The process of determining specific objectives, goals, and actions designed to meet the client’s needs as identified through the assessment process. The plan should be action-oriented and time-specific.
Both short term and long term goals should be developed. The short term goals should be directly related to the long term goals. The actions are the treatments and services needed to meet the clients needs and goals.
The objective of this phase is to develop the case management plan of care. According to CCMC this is, “A timeline of patient care activities and expected outcomes of care that address the plan of care of each discipline involved in the care of a particular patient. It is usually developed prospectively by an interdisciplinary healthcare team in relation to a patient’s diagnosis, health problem, or surgical procedure.”
The Commission for Case Management Certification(CCMC) defines implementation as, “The process of executing specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan.” This is where we coordinate care by organizing, securing, integrating and modifying the resources needed for the client to reach the desired outcome. The case manager acts as a liaison between the client, their support system and/or caregivers, providers, and payer/insurance company.
During the follow-up phase the case manager gathers information from the patient, caregiver and all relevant sources. This information is evaluated to determine the effectiveness of the current case management plan, in moving the client toward the desired outcomes. Modifications are made to the plan as needed, and ongoing follow-ups determine the effectiveness of the modifications.
Errors often occur when patients are transferring from one health care setting to another, or home after a hospital or facility stay. The case manager can reduce these errors by education the family and caregivers on post transition care and follow-up. They can also help maintain continuity of care between care settings by relaying relevant information to the members of the new healthcare team. In addition they can secure DME, home health or other needed services and equipment ensuring a smooth transition to home.
Following an episode of care, the Case Manager will follow-up the the client and/or caregiver to determine how things are going. Medication management, self care ability, compliance with follow-up appointments, satisfaction with home health or outpatient therapies are some the the areas that may be evaluated. Any issues or problems discovered are addressed during this phase and additional follow-ups are done to ensure resolution.
This is where we assess the effectiveness of the case management plan of care and it’s effect on the clients condition. The evaluation focuses on several areas including a financial evaluation, done with a cost-benefit analysis and return on investment, clinical outcomes, quality of life, client satisfaction, self-care management ability and knowledge of health conditions and plan of care.