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case management

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By J. P. Bradley

three registered nurses writing on patients chartsCase Management in nursing is an evolving practice specialty. The role of nurses in case management is to supervise and coordinate healthcare for patients with long-term illnesses. Such patients require long-term therapy and careful planning of all aspects of treatment. For instance if there is a patient suffering from cancer , the nurse who is assigned the role of the nurse case manager must arrange for doctor’s appointment, drugs, radiation, surgery or chemotherapy. A nurse case manager usually works in a specific practice specialty such as cancer, pediatric or cardiovascular disease.

Among the goals of case management nursing is to coordinate the care of patients. Since there are other specialists involved such as therapists, surgeons and other doctors, a nurse in case management will coordinate and keep the records of all their activity while updating the patient accordingly on the progress. According to the health problem at hand, the nurse can also decide what the other specialists should examine the patient so that there is collaboration of efforts by all. The nurse also ensures that all the procedures performed on a patient are at the highest level, increasing the chances of the expected outcome. In so doing, all the resources are used efficiently without any wasted or over usage of care resources.

Case Management in Nursing

The role of the nurse in case management can be defined in 3 basic ways, or a combination of any, according to the individual hospital setting as follows:

Quality Management

In larger hospitals, this aspect of quality management may be separated from the normal case management. The nurse is assigned the role of ensuring that all the services provided are of high standards. In smaller hospitals though, the finances may not allow for separation of duties and the case management nurse does all the work involved. The nurse is responsible for the general quality of health care being delivered, and can also assist in the risk management office when legal matters arise during a patient’s treatment.

Utilization Review

This type of case managers review different elements of the various hospital systems, guided by the terms of the hospital or the insurance company that is in charge. Prompt service delivery as well as adequate and safe utilization of the service is also a responsibility under this docket. The nurse is specially of essence in relation to insurance, because he/she approves and certifies acute and non-acute admissions. This information is then passed on to the insurance company under which the patient is covered. The nurse uses what is known as ‘InterQual Criteria’ which is a standardized method of identifying diagnoses, probable complications, procedures required and the timelines during which to account for a shifting diagnoses.

The Utilization Review nurse coordinates with the quality manager physician to administer high quality services to the patient. For instance if the patient has improved and no longer needs acute care, the nurse can consult the QM physician to see if the patient can be transferred to outpatient care or other suitable services. Before making a decision, the physician will review the patient’s chart, current situation and discharge plan. If in agreement the recovering patient can be moved to a lower level of care. To qualify for a post of Utilization Review Manager nurse, a three-year experience in  an acute hospital setting is advisable.


Discharge Planning

The role of this nurse in case management is to coordinates all the elements of admission or discharge of a patient. According to the InterQual Criteria, this nurse deals with the high risk patients with chronic diagnoses such as complicated pneumonia or stroke. The nurse combines all the available social and financial services to come up with a viable and safe discharge plan. A discharge planning nurse can cover up to forty patients at a time depending on the individual hospital policy. It is ideal however to have no more than twenty patients. Past experience together with assessment abilities are used to review the patients current situation, medical history and family support before formulating a discharge plan. A discharge planner should be familiar with Medicare guidelines, InterQual Criteria as well as fees for service items that enable a patient to be given a different level of care. These are some of the important things that should be known.

Nursing case management is a growing practice specialty. Many registered nurses are taking advanced case and care management programs to increase their knowledge and skills to practice in this area. As health care continues to reform, we will see this nursing specialty increase in demand and in importance.


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