There are 6 steps of case management and the first step toidentify the patient. The case manager will identify clients who will benefit fromthe case management service based on certain specific criteria. The will be ascreening or an assessment tool will be used to assist in identifying theclient.
Important key information may include health services utilization, pastand current health condition, socioeconomic and financial status, healthinsurance coverage, home environment, prior services,physical/emotional/cognitive functioning, psychosocial network and supportsystem, and self-care ability. One type of screening tool would be the Coleman’smodel focuses on the four pillars which are medication self-management, use ofa dynamic patient-centred record, primary care and specialist follow-up and knowledgeof red flags. Next is the assessment to identify the actual and potentialproblems to rise. This is to know the needs of the patient so that tocategorise in transitional care or discharge plan. After assessing the patient,the case manager will set goals and plan necessary intervention and engage on theappropriate resources. The two main parts of this is to identify the client’skey problems that needs to be addressed, as well as individual needs andinterests.
And, developing a comprehensive case management plan of care thataddresses these problems and needs. One example is when the case manager isconducting a home visit. The case manager must take note of the livingcondition of the patient adherence to certain treatments. The case manager willthen conduct an assessment for example, for patients with chronic illness must knowtheir risks and the signs and symptoms. They also must remind the clients aboutupcoming appointments. There are 3 types of geriatric assessment which are cognitiveand affective assessment, social assessment and functional assessment. This type of assessment is for case managersto obtain information about functional performance about older adults. Planning is the next step which is to establish goals and theneeds of the patient as well as the types of services needed will be the toppriority so that to be able to achieve the desired outcome.
Planning also helpsto reduce risks and it also helps the patient to have a smooth journeythroughout. Case managers may consider the services in the community that can bebeneficial for the patient. The case management plan of care identifiesoutcomes that are achievable within an appropriate time frame and that applyevidenced-based standards and care guidelines. Planning is completed aftergetting authorization for the health and human services to be rendered has beengiven and after the services and resources needed have been identified.Implementation is next whereby the case manager willcoordinate the activities for the patient and will reassess the patient frequentlyso that to identify if there is any modification needed. For example, if thepatient is an elderly and is living alone, there might be a high risk ofinjuries. Hence, the case manager will arrange home occupational therapyassessment get referral from social workers and engage for financialassistance.
The case manager asks about the client’s comfort with self-care, intakeof medications, availability of post-transition services (e.g., visitingservices), and presence of any issues. The case manager gets feedback regardingthe client’s experience and satisfaction with services rendered. The casemanager also follows up on issues and problems identified during thepost-transition communication and seeks resolution on these issues. Also, the casemanager reports the feedback gathered during the communication to keystakeholders such as payors and providers of care.
Depending on the issue orconcern identified, the case manager may engage other healthcare professionalsto reach resolution.The case manager will then evaluate the patient careactivities and examines the patient condition and the status of their goal. Duringthis phase, the case manager generates outcome reports such as case summary,cost/billing, satisfaction, outcomes, cost-benefit analysis, and return oninvestment. The case manager communicates the findings or disseminates thereports to key stakeholders such as government agencies, client, payor,providers of care, employers, interdisciplinary team members, risk managementstaff, quality improvement team members, and others as deemed appropriate.Lastly, when the patient has achieved the desired goal basedon their choice or from their family members, the case manager is no longerneeded to provide services and hence the termination of the case managementprocess.