Professional Case Management最新文献

Purpose/objectives: The purpose of this article is to inform the reader of the practice of the registered nurse care coordinator (RNCC) within an interprofessional, nurse-led clinic serving uninsured diabetic patients in a large urban city. This clinic serves as a transitional care clinic, providing integrated diabetes management and assisting patients to establish with other primary care doctors in the community once appropriate. The clinic uses an interprofessional collaborative practice (IPCP) model with the RNCC at the center of patient onboarding, integrated responsive care, and clinic transitioning.

Primary practice setting: Interprofessional, nurse-led clinic for uninsured patients with diabetes.

Findings/conclusions: Interprofessional models of care are strengthened using a specialized care coordinator.

Implications for case management practice: Care coordination is a key component in case management of a population with chronic disease. The RNCC, having specialized clinical expertise, is an essential member of the interdisciplinary team, contributing a wide range of resources to assist patients in achieving successful outcomes managing diabetes. Transitional care coordination, moving from unmanaged to managed diabetes care, is part of a bundled health care process fundamental to this clinic's IPCP model. In a transitional clinic setting, frequent interaction with patients through onboarding, routine check-ins, and warm handoff helps support and empower the patient to be engaged in their personal health care journey.

Purpose/objectives: Care transitions from one setting to another are vulnerable spaces where patients are susceptible to complications. Health systems, accountable care organizations, and payers recognize that care transition interventions are necessary to reduce unnecessary cost and utilization and improve patient outcomes following a hospitalization. Multiple care transition models exist, with varying degrees of intensity and success. This article describes a quality improvement project for a care transition model that incorporates key elements from the American Case Management Association's Transitions of Care Standards and the Transitional Care Management services as outlined by the Centers for Medicare & Medicaid Services.

Primary practice setting: A collaboratively developed care transition model was implemented between a health system population health management office and a primary care organization.

Findings/conclusions: An effective care transitions model is stronger with collaboration among core members of a patient's care team, including a nurse care manager and a primary care provider. Ongoing quality improvement is necessary to gain efficiencies and effectiveness of such a model.

Implications for case management practice: Care managers are integral in coordinating effective transitions. Care management practice includes transition of care standards that are associated with improved outcomes for patients at high risk for readmission. Interventions inclusive of medication reconciliation, identification and addressing of health-related social needs, review of discharge instructions, and coordinated follow-up are important factors that impact patient outcomes. Patients and their health system care teams benefit from the role of a care manager when there is a collaborative, coordinated, and timely approach to hospital follow-up.

Purpose/objectives: An increase in the use of remote therapeutic monitoring (RTM) has been spurred by nationwide factors including the COVID-19 pandemic, authorized reimbursement of RTM by the Centers for Medicare & Medicaid Services, and more frequent use of big data analytics in health care delivery. This article discusses the use of RTM by care teams at the point of care and explores the role of the case manager in RTM to address patients' unmet needs.

Primary practice settings: Although RTM may be utilized across inpatient and outpatient levels of care, this article focuses on outpatient care such as community clinics, provider groups, and home health care.

Findings/conclusions: When implemented along with care management interventions, RTM applications have the potential to improve patient adherence, enhance communication between patients and their providers, streamline resource allocation, and address social determinants of health impacting patient care and outcomes.

Implications for case management practice: RTM reimbursement models are rapidly evolving, utilizing real-world and patient-reported data to identify and initiate timely, individualized solutions that meet the holistic needs of each patient. Use of an RTM system allows the case manager to build rapport with the patient while quickly identifying care gaps and delivering appropriate interventions that can maximize patient outcomes. RTM can drive savings and bring revenue to the system or practice while providing salient documentation of social determinants of health that can be addressed with validation of proven care coordination interventions.