The Case manager最新文献

The team approach to case management (CM) has proven to be an effective method of providing quality outcomes, reducing fragmentation of care, improving communication, and reducing cost.¹ Often CM teams consist of the patient, family/caregiver, physician, case manager, other health care personnel, clergy, home health agencies, employers, and health-plan administrators. This article focuses on the CM process implemented within a former TRICARE region to bridge the gap between the primary care manager (PCM) and CM. It discusses how the TRICARE Mid-Atlantic region identified and resolved barriers effecting collaboration between the PCM and CM.

The Commission for Case Manager Certification (CCMC) defines case management (CM) as “a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs. [Case management] uses communication and available resources to promote quality, cost-effective outcomes.”¹ The practice of CM spans the entire health-care spectrum, including preacute, acute, and postacute settings, and the involvement of varied care providers, such as nurses, social workers, rehabilitation counselors, physicians, and other allied health professionals. So what does it mean to practice as a case manager? What roles and job functions are performed and what knowledge is required of a professional in the field for effective practice?

These highly relevant questions reflect the thinking of the CCMC commissioners when the latest Case Manager Role and Functions study was undertaken. The primary purpose of this research, which is conducted every 5 years by the CCMC, is to capture the current state of CM practice. This type of in-depth research is required to support an evidence-based certification examination such as the one offered by CCMC—the certified case manager (CCM) credential. Moreover, as the first and largest nationally accredited organization to certify US case managers, the CCMC recognizes its responsibility to undertake and promote scientifically conducted research in the field of CM.

The health-care system works, for the most part, and patients who need help from case management are the exception rather than the rule. This has always been my belief, and this is what I have always advised. We even had statistics: 5%–10% of Medicare patients are high risk and need a case manager, and 6%–10% of patients account for 85%–90% of costs. Although these figures may be accurate, the small percentage indicating patients who need a case manager is no longer accurate. The health-care system is fraught with pitfalls, bureaucracy, disinterest, and delay. Even straightforward care is no longer straightforward in its delivery. Case managers may not be the answer to the woes of the health-care system, but we are surely the patient's last hope for navigating the maze.

Think about it—you graduated from medical school, a pharmacy, or nursing program and have been working in the world of health care free of books and tests for a number of years. There are no professors to keep you stimulated, no tests to ensure you keep up to date with the information required to complete your program, and no self-induced stress that pushes you to strive for that “A” to keep your grade point average up. So what is your motivation for keeping up with changes in today's fast-paced health-care world?

With the unrelenting development of new medical technologies and increasingly more complex treatments, health-care providers sometimes find themselves faced with requests to provide treatments they believe to be medically futile. This language and resulting argument based on it can produce an adversarial posturing on the part of providers and families that frequently anticipates or threatens a legal solution. Although our legal system will choose sides on an issue, futility cases that have ended up in the courts have generally failed to definitively answer questions about how to address future dilemmas. A more helpful process is a clear procedure for addressing both sides of the question with the ultimate decision-making remaining within the health-care setting. The ethically appropriate solution lies within the context of a shared decision-making process between patient/family and physician/health-care provider that honors the values of both parties without assuming a unilateral decision-making stance. Case managers and direct-care providers, when faced with requests for treatments deemed to be medically inappropriate or futile, are challenged to understand and pursue this shared process.