Description

Case Management Definition:

CMSA approved definition: Case Management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individuals health needs through communication and available resources to promote quality cost-effective outcomes.

CMSA Case Management Role: The role of the Case Manager is to collaborate with clients by assessing, facilitating, planning and advocating for health needs on an individual basis. Successful outcomes cannot be achieved without specialized skills and knowledge applied throughout the process. These skills include, but are not limited to, positive relationship building, effective written/verbal communication, ability to effect change, perform critical analysis, plan and organize effectively and promote client/family autonomy. It is crucial for the Case Manager to have knowledge of funding resources, services, and clinical standards and outcomes.

Case Manager Standards of Performance:

• Quality of Care:
• Case manager will provide an appropriate, timely and beneficial service to all patients which promotes quality and cost-effective health care outcomes

UM Case Manager Responsibilities:

• Salary position
  • Monday to Friday from 8am to 5pm
  • May require weekend coverage on call rotation
• Daily review of Hospital and Skill Nursing Home inpatient list
  • Case Review forms to UM / Quality Department by 4:00 PM New admissions
  • Daily updates from Hospital and/or SNH Case Managers
  • To provide information to Hospital and/or SNH Case Manager
  • To coordinate post in patient admission services and office follow up
  • To obtain medical records from Hospital and/or SNH for office follow up
  • Family dynamics and support systems
• Coordinate with PCP and Care Team at Facilities any possible admissions and/or ER diversions to a Skilled Nursing Home
• Notify Skilled Nursing Home admitting physician and Case Manager of any possible admissions and provide medical information as needed
• Maintain appropriate documentation in available systems EMR and any other CM software
• Contact high risk patients when they are no shows.
• Document in the chart the reason and reschedule
• Regular interaction with office Care Team to review elective/future inpatient and outpatient procedures.
  • Review w/ PCP
  • Review Pre-op clearance w/ office staff
  • Notify UM/Quality Department Director of upcoming inpatient procedures
• Review all out of the area admissions and keep a daily report
• Notify Medical Economics/ Data Department of all out of area admissions
• Daily review of office schedules to identify any patients that need Case Management intervention.
• Recent Hospital/SNH discharges
• Disease Management
• Education on Advanced Directives, Community Services information
• Case Management System
  • Maintain most current patients information
  • Tracking system for Hospital/SNH admissions and Disease management
• To identify patients for Disease Management and follow up according to protocol
• CAD/CHF/COPD/DM/CKD Disease Management
• New patient orientation: All HMO Managed Care Advantage new members orientation within the 1^st month of enrollment
  • Completion of: Mini Mental, ADLs screening, psychosocial assessment (See new patient orientation form)
  • Identification of any transfer for cause members or reallocation cases
• To maintain monthly logs:
  • ESRD-End Stage Renal Disease Log: Form 2728 ESRD Medical Evidence Report
  • Hospice Log Certification Forms
  • Oncology Log
  • Transplant Log
  • CAD/CHF/COPD/ Diabetes / CKD Disease Management Log
• To follow up protocols of
  • Case Management
  • Disease Management
  • Transitions of Care

Qualifications

Education, Preparation, Certification Qualifications:

Care Coordinator Social Work Degree

• Current nursing license with the State of Florida, LPN or RN
• Case Manager will work towards and maintain Case Management Certification
• Case Manager will maintain continuing education appropriate for case management and professional licensure
• CPR/BLS certification

Collaboration:

• The Case managers role requires collaborative, proactive and patient-focused relationships to facilitate, and maximize client healthcare outcome.

Legal:

• The Case Manager practices in accordance with applicable laws.
• Be knowledgeable of the legal scope of practice of various healthcare providers: Confidentiality and release of information. HIPAA guidelines.

Ethical:

• The Case Manager will be guided by ethical principles and will provide service with respect for autonomy, dignity, privacy and rights to the individual.

Case Manager Skills:

• Communication / Coordinate sharing of pertaining information
• Critical Thinking / Problem solving/Computer
• Clinical background / Case screening and identification / Referral coordination
• Negotiation and collaboration / Knowledge of community resources
• Patient advocacy and empowerment /Conference and meetings