Introduction
It is very vital for the individuals in the medical field to have specialization in order for them to have a great opportunity and the capacity to deal with critical issues which the health care system is currently facing across the world. It is worth noting that the nurse plays an important role in the healthcare sector. This is because he/she is an active member of the team working to save the patient’s life as well as secure his/her safety and give an appropriate treatment.
The basic goal of becoming a nurse is to offer help to individuals in order for them to achieve the highest level possible of well-being. The main goal of nursing is to meet all the needs of the patients, considering the individual culture and psychological and physiological features as well. The nurses work to improve the health of people, to ensure disease prevention, and to assist the patients to cope with diseases (Delamaire & Lafortune, 2010).
However, there arise cases in which the nurse’s abilities and responsibilities are specifically the ones that are required by the patients. This comes about in the case where the patients are found out to be individuals having specific and complicated needs in regard with their hospital and home treatment. There exist the special hospitals as well as health institutions that do their best to provide their patients with all they require. The case managers in these hospitals work to meet the needs of the patients in critical conditions or those having high-risk complex needs (Chan, et al, 2000).
This is in line with the belief that the case manager’s function to this category of patients will bring improvement in the general condition and welfare of the patient (Chan, et al, 2000). In this paper, there is going to be a discussion of the ways in which the nurses have applied case management concepts to care for patients that have high-risk complex needs both inside and outside the hospital over time. The discussion will start by looking at case management and the general benefits that come from the application of its concepts and then, there is also going to be a discussion on the application of case management concepts. The paper will end with a conclusion in which the summary of the main points in the paper is going to be given.
Case Management
White et al (2006) defines case management as “a care delivery model designed to coordinate and manage patient care across the continuum of health care system” (White et al, 2006, p.99). Those who are involved in case management are normally engaged in the whole period of illness/disability or need for services. The case management practice is dependent greatly on the kind and structure of the organization. Even if the case managers can come from a large number of disciplines, most of these managers do have a background in either social work or nursing (Powell, 2000). The nurses are in a better position to play the role for the reason that the case management functions follow closely the framework of the process of nursing which involve planning, assessing, implementing and evaluating.
Case management, being a process, makes this framework to be wider and ensures incorporation of additional components which include “patient identification, resource identification, advocacy, coordination, monitoring, and evaluation of care, data collection and analysis, and documentation of multiple outcomes, including cost, quality and client status” (Cesta & Tahan, 2003, p.69). Because of its intrinsically collaborative as well as multidisciplinary nature, the case management process facilitates involvement of the patient, the family and other health care team members. Care coordination promotes efficient resource utilization. But, even in the period of managed care, while controlling the cost is vital, it is not the only goal. The care quality, continuity, and the guarantee of suitable and well-timed interventions are important (Reel, 2002).
The case management practice is very much involving and to a large extent, is still dependent on the setting (Bergen, 2003, p.16). Basing on history, it is established that the preparation for the nurse case manager took place in the health care organization and “was specific to the role, responsibilities, and scope of practice in the institution” (White et al, 2006, p.100). In the more recent times, it has been found out that there has been embracing of the preparation for nurse case managers within the academic setting. However, it is pointed out that “regardless of academic preparation, to be effective, the nurse case manager must possess clinical expertise, effective communication and problem solving skills, and broad knowledge of health care system, including financing, regulations and resources” (Tholcken, Clark & Tschirch, 2004, p.45).
Benefits and Outcomes of case Management
Case management brings in several benefits. For instance, case management offers a single point of contact for the client, and the nurse among other service providers. The one who engages in case management navigates the system with the client as well as with the carer and by doing this, the case manager offers additional support for families (CMSA, 2006). Another benefit is that case management facilitates optimal use of available resources. It identifies the most suitable kind and level of support or service. It arranges a tailored care package to meet the specific needs of an individual and in turn monitors to make sure there is delivery of servcies. This brings about better use of the resources that are available through having improved coordination of services (CMSA, 2006).
Moreover, case management supports independence and provides confidence. A larger number of people show a desire to remain staying in their own homes for the longest time possible. Among the main factors that contribute to people moving from their homes to the residential care is the lack of security and confidence. There is need to have confidence in the physical capability to manage at home and also the psycho-social capability. Case management offers care package together with the security having one individual that one can contact in case he/she had any hardships. This combination offers a sense of safety or security that one can remain staying at home and receive sufficient support (CMSA. (2006).
Case management can also serve as an alternative to residential care. The literatures that have been presented indicate that intensive, case managed community services offer alternatives to access to residential care (CMSA, 2006). One of the main goals of a large number of community care programs is to bring down the level of inappropriate admission to the residential care alternatives. Generally, case management is among the ways of helping to achieve the goals of community care (CMSA, 2006).
Moreover, since case management operates to tailor what is available in order to meet particular needs of the client and can engage in venturing outside the realm of what is generally available in community care, it is frequently the service innovation driver (CMSA, 2006).
Also, in an assessment that was carried out in the in recent times of the ‘New Wales ComPacks program’, it was indicated that out of the total number of individuals who stayed in the hospital for more than three weeks, those referred to ComPacks stayed approximately “9.8 days less than people not referred to ComPacks” (CMSA, 2006, p.11). The delivery of ComPacks is done for thirty dollars per day as compared to three hundred and fifty dollars per day for the in-patient sub-acute care. This is an indication that case management can help in reducing the utilization of health services and is remarkably more cost effective (CMSA, 2006).
Applying case Management Concepts
According to Raven (2011), a small proportion of the Medicaid patients, a large number of whom are affected by the multiple diseases encompassing substance use and mental illness, account for unbalanced share of the emergence department or ED and inpatient visits as well as costs (Raven, 2011, p.1). In overall terms, about four percent of Medicaid patients account for about fifty percent of Medicaid spending, around $88 in 2001 (Billings & Mijanovich, 2007). Such high-cost cases have attracted the policy makers’ attention and a large number of state leaders are putting focus on this small group of “the highest-cost beneficiaries as a way to bend the cost curve and improve quality of care” (Bella, et al, 2008, p.18). These factors present a need to set up effective models to offer cost-effective care for the highest users of health servcies.
Raven (2011) points out that a number of interventions aimed at assisting the high-risk patients in Medicaid and other arenas have given a demonstration of success in the cost control, at the same time bringing down the level of frequent utilization of emergency department as well as in-patient services. A randomized control trial that was carried out recently in Chicago indicated that offering housing and case management to the homeless adults having chronic conditions brought down the level of the future hospital days and emergency department visits (Sadowski, Kee, VanderWeele & Buchanan, 2009).
Another study still conducted in Chicago showed that giving respite care to the homeless patients after being discharged from the hospital reduced future hospitalizations (Buchanan, 2006). A randomized trial targeting the frequent emergency department users in San Francisco portrayed a decrease in hospital admissions (Shumway, et al, 2008). A number of other studies have shown success in bringing down the level of hospitalizations as well as the costs with case management plans targeting the seriously mentally ill patients and the elderly (Cox, et al, 2003; Naylor, et al., 2004).
Looking at case management programs for patients having the coronary heart diseases, Kirchberger, et al. (2010) point out that several intervention trials sought to find out if a case management may have control over “patient readmission” and other results in this disease. It could be indicated that secondary prevention programs “positively affect the process of care, survival, and functional status or quality of life of patients with CHD independent of the applied program” (Kirchberger et, al, 2010, p.2).
In another study conducted by McAlister, et al (2001) it was indicated that “comprehensive case management programmes have a positive effect on processes of care in patients with CHD: there was a significant reduction in admissions to hospital and an improvement in quality of life” (Kirchberger, et, al, 2010, p.2). However, it is also pointed out that there was no documentation of any survival advantage or a decrease in the repeated MI that was carried out by the “randomized clinical trials” (Kirchberger, et al, 2010, p.2).
Even if the results presented by the two studies are promising, there can be no generalizing of the findings presented by the studies to higher age groups. The research conducted by Naylor et al, (2004) evaluated a discharge arrangement that was nurse-centered and home follow-up involvement in the patients who were beyond the age of sixty five with a wide disparity of involvement and diagnoses. The study they conducted on the elderly people having CHF gave a demonstration that the intervention remarkably increased the duration between hospital discharge and re-admission or death, “reduced total number of re-hospitalizations, and decreased healthcare costs” (Naylor et al, 2004, p.680).
Conclusion
The case management concepts have been applied by nurses in order to help the patients having complex and high-risk needs. There are several benefits that come with this and this include optimal use of the available resources, supporting independence and providing confidence, reduced use of health services, service innovation, and having an alternative to residential care. Therefore, it is important to ensure there is continual application of the case management concepts by nurses to care for patients with high-risk complex needs, both inside and outside the hospital and over time.
References
Bella, M, Shearer C, Llanos K, & Somers S.A (2008). Purchasing strategies to improve care management for complex populations: a national scan of state purchasers. Hamilton, NJ: Center for Health Care Strategies, Inc.
Bergen, A. (2003). Care management revisited: a follow-up study. Br J Community Nurs; 8(1),16–23.
Billings J,& Mijanovich T. (2007). Improving the management of care for high-cost Medicaid patients. Health Aff , 26 (1),1643-54.
Buchanan D, Doblin B, Sai T, Garcia P. (2006). The effects of respite care for homeless patients: a cohort study. Am J Pub Health, 96 (1),1278-81.
Cesta, T.G. &Tahan, H.A. (2003). Role of the case manager. St. Louis, MO: Mosby.
Chan, S., McKenzie, A., Tin-Fu, D., & Ka-yi Leung, J. (2006). An evaluation of the implementation of case management in the community psychiatric nursing service. Journal of Advanced Nursing, 31 (1), 21 – 36.
Cox W.K, Penny L.C, Statham R.P, & Roper B.L (2003). Admission intervention team: medical center based intensive case management of the seriously mentally ill. Case Management, 4(1),178-84.
CMSA. (2006). Case management and community care: A discussion paper. Web.
Delamaire, M. and G. Lafortune (2010). Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries”, OECD Health Working Papers, No. 54, OECD Publishing.
Kirchberger, I. et al. (2010). Nurse-based case management for aged patients with myocardial infarction: study protocol of a randomized controlled trial. BMC Geriatrics, 10(29), 1- 8.
McAlister, F.A, Lawson F.M, Teo K.K, Armstrong P.W (2001). Randomized trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ, 323(1), 957-62.
Naylor M.D, Brooten D.A, Campbell R.L, Maislin G, McCauley K.M, Schwartz J.S (2004). Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc, 52 (1), 675-84.
Powell, S.K. (2000). Overview of case management. Philadelphia, PA: Lippincott.
Raven, M. et al. (2011). An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study. BMC Health Services Research, 11 (1),1 -10.
Reel, S.J, Morgan-Judge T, Peros D.S, & Abraham I.L. (2002). School-based rural case management: a model to prevent and reduce risk. J Am Acad Nurse Pract.14(7),291–6.
Sadowski, L.S, Kee RA, VanderWeele T.J, Buchanan, D: (2009). Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA, 301(1),1771-8.
Shumway, M, Boccellari A, O’Brien K, Okin R.L. (2008). Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med, 26:155-64.
Tholcken, M, Clark M.C, &Tschirch P. (2004). Case management in the undergraduate Curriculum. J Nurs Educ.; 43(1),45–8.
White, P. et al. (2006). Mapping the literature of case management nursing. J. Med L:ibr Assoc., 94(2), 99 – 106.