1. NURSING CASE MANAGEMENT
AND CRITICAL PATHWAYS OF
CARE
PRESENTED BY
MS JIYA G PANTHANALIL
IST YEAR MSC NURSING
NIMHANS, BANGALORE

2. INTRODUCTION
 Concept of case management evolved with advent of
diagnosis related groups (DRGs) and shorter hospital
stays
 Innovative model of care delivery that can result in
improved client care
 Clients are assigned a manager who negotiates with
multiple providers to obtain diverse services
 Decreases fragmentation of care

3. DEFINITION
• Managed care refers to a strategy employed by
purchasers of health care services who make
determinations about various types of services in
order to maintain quality and control costs

4. Managed care exists in many settings:
• Insurance –based programs
• Employer –based medical providerships
• Social service programs
• The public health sector

5. FEATURES OF CASE MANAGEMENT
• Method used to achieve managed care
• Actual coordination of services with in the
fragmented health care system
• Strives to help at-risk clients
• Controls health care costs to consumer and third
party payers

6. COMPONENTS
Case finding
Assessment
Care planning
Care co-ordination

7. CASE FINDING
• Systematic method
• identify individuals who are at risk of hospital
admissions
• Aims at preventing unplanned admissions
• Patients who are currently experiencing multiple
emergency admissions have fewer emergency
admissions in future- ‘regression to the mean’
• Identify the patient before they deteriorate

8. ASSESSMENT
• Assessment of current level of ability
• Physical and social care needs
• Assessment is not restricted only to health needs

9. CARE PLANNING
Care plan address individuals’ full range of
needs including
• Health, personal, social, economic, educational,
mental health, ethnic, and cultural background
and circumstances
Care plan provides structure to individual’s care
and ensure that goals of different services are
aligned with each other

10. Care plan enables case manager to
• Make referrals to various services
• Co-ordinate all the different services he/she
should liaise with
• Ensure that referrals have been picked up and
acted on
• Monitor whether individual has made any
progress

11. • Care plan should be viewed as a live document
• Review the individual’s health and social care
needs and revise the care plan accordingly
• Care plan is in a constant state of change
• It depends on individual’s condition and how
much progress has been made
• It is an ongoing process that structures and
facilitates effective delivery of care over time

12. CARE CO-ORDINATION
Reduce duplications of
health care
Avoid gaps and reduce
health and social care service
costs
Improved disease
management
Faster discharge from
hospital

13. COMMON ACTIVITIES IN CARE CO-ORDINATION
1. MEDICATION MANAGEMENT
-Ensure that individual’s medication regimen is appropriate and
upto date
-adherence of treatment regimen and monitor for
adverse effects
-communicate with individual patient, general
practice staff, specialists, pharmacists

14. 2. SELF CARE SUPPORT
Providing general health education and advice
Providing health education and advice specific to
individual’s long term conditions
Coaching about most appropriate service to contact
related to health or when a crisis occurs

15. 3. ADVOCACY AND NEGOTIATION
• Facilitates patient to have access to services and
equipment identified in the care plan
• Case manager directly negotiate with service
providers
• Speed up the process of obtaining medication,
equipment or home care services

16. 4. PSYCHO SOCIAL
SUPPORT
• Good relationships fostered by
regular contact make patients
more confident and increase
well being
• Psychological support is a key
strategy in supporting self care
• Helps to identify and support
individual to behavioural
change and facilitate changes in
future goals

17. 5. MONITORING AND REVIEW
• A well written care plan is the basis for review
• Frequency of monitoring depends on individual’s level of need
• Monitoring can take place
Daily
Weekly
Monthly
Directly in individual’s home
Through remote monitoring(by telephone, telehealth device)

18. TELE HEALTH SERVICE

19. 6. CASE CLOSURE
Four possible methods of discharge from case
management programme
• Death
• Self discharge
• Decision by the case manager and multidisciplinary
team
• patient’s risk of hospital admission identified by a
risk prediction tool falls below a certain level as
determined by case management programme

20. FACTORS DETERMINING EFFECTIVE
CASE MANAGEMENT
The key enabling factors include
Role and skills of case manager
• Assigned accountability
• Role and remit
• Skills and support
• Building relationships

21. Programme design
• Targeting and eligibility
• Manageable case load
• Single point of care
• Effective use of data and communication processes

22. Factors within the wider system
• Shared vision and objectives
• Close links between health and social care
• Aligned financial flows and incentives
• Stakeholder engagement
• Provision of services in the community

23. ROLES AND SKILLS
• ASSIGNED ACCOUNTABILITY
Successful case management requires an individual
or team with oversight of , and is accountable for the
whole processes
Risk of fragmented care when accountability is not
clearly assigned

24. • ROLE AND REMIT
Clarity around the roles, responsibilities and
boundaries of team members facilitate case
management
Confusion over roles can lead to tension
Perceived seniority of one service over another, and rivalry
between different professionals can cause problem

25. • SKILLS AND SUPPORT
Key skills that case managers need include:
Inter personal skills
Problem solving skills
Negotiation and brokerage skill
Prescribing qualifications
Training

26. • BUILDING RELATIONSHIPS
Case managers and their patients
Case managers and GPs
Case managers and hospital staff

27. PROGRAMME DESIGN
• TARGETING AND ELIGIBILITY
Case finding helps in finding target cases(most at risk
and can benefit most)
Where targeting is not accurate, programme will not
be cost effective
Programme should set out clear criteria for discharge

28. • MANAGEABLE CASE LOAD
Multiple roles include direct
patient care, administrative tasks,
attending or delivering training sessions and attending
meetings
It can affect case managers’ capacity to provide care
for all patients

29. Number of patients manageable in a case
load is influenced by:
• Nature of patient’s conditions
• Patients socio-demographic profiles
• Patient’s circumstances
• patient’s geographical area
• patient’s individual characteristics
• Time needed for non clinical activities

30. • SINGLE POINT OF ACCESS/SINGLE
ASSESSMENT
Information sharing protocols can help to facilitate
assessment process
Single Assessment Process (SAP) introduced in 2001
aimed to reduce duplication in health and social care
SAP was designed to standardise assessment across
different agencies and settings to raise overall
standard of care and uniformity

31. • CONTINUITY OF CARE
Case manager should retain oversight over the
entirety of individual’s situation over time.
It gives a valuable sense of continuity for the patient

32. •EFFECTIVE USE OF DATAAND
COMMUNICATION PROCESSES
Case management depends on exchange of
information between partners working in different
teams
All information is streamed centrally through case
manager
Constant communication and timely information
exchange with multidisciplinary team is vital
Critically patient has a single point of contact to
whom they can address any queries or concerns

33. FACTORS WITHIN THE WIDER
SYSTEM
• SHARED VISION AND OBJECTIVES
Case management need to develop clear goals and
objectives
It should be understood by all partners
Sense of shared responsibility and collaborative
approach facilitate better co-ordination of care
Where different partners or elements of system do
not share same vision, care co-ordination is difficult

34. • CLOSE LINKS BETWEEN HEALTH AND
SOCIAL CARE
People with complex needs nearly always require
support from both health and social care services
Social care is particularly important for patients in
rehabilitation and re- ablement phases

35. •ALIGNED FINANCIAL FLOWS AND
INCENTIVES
Different funding options have been used to support
case management
 Pooled budgets: eg. Castlefields example
 Capitation: Fixed sum of money per patient can be
used for a package of care services, where case
management team takes responsibility for a patient’s
care over time

36. STAKEHOLDER ENGAGEMENT
1. Case management needs
trust, support and
enthusiasm of local
stakeholders
2. engage key professionals
and teams in the case
management

37. •PROVISION OF SERVICES WITH IN THE
COMMUNITY
• Case managers need to draw on a range of
resources and services in the community
• It helps patient to receive care at home
• Community resources must be effectively
commissioned and case managers should know
what is available and how to access it

38. ROLE OF NURSE AS CASE MANAGER
• Advocacy and education
• Clinical care coordination/facilitation
• Continuity/ transition management
• Performance and outcomes management
• Psychosocial management
• Research and practice development
• Utilisation review
• Quality management
• Discharge planner

39. CRITICAL
PATHWAYS OF
CARE

40. DEFINITION
• A care pathway is anticipated care placed in an
appropriate time frame, written and agreed by a multi
disciplinary team-Welsh National Leadership and
Innovation Agency for Health care(2005)
• A critical pathway is a type of abbreviated plan of
care that provides outcome-based guidelines for goal
achievement within a designated length of stay.

41. CPC TEAM INCLUDES
• Nurse case manager
• Clinical nurse specialist
• Social worker
• Psychiatrist
• Psychologist
• Dietician
• Occupational therapist
• Chaplain and others

42. HOW CPC IS CARRIED OUT
• The team decides what categories of care are to be
performed, by what date and whom
• Each member of the team is then expected to carry
out his or her functions according to the time line
designated on the CPC
• The nurse as case manager is ultimately responsible
for ensuring that each day of assignments is carried
out

43. • If variations occur at any time in any of the categories
of care, rationale must be documented in the progress
notes
• The nurse contacts psychiatrists to inform him or her
of the admission
• The psychiatrist performs additional assessments to
determine if other consultations are required

44. • Within 24 hours, the interdisciplinary team meets to
decide on other categories of care
• Completion of the CPC, and make individual care
assignments from the CPC
• Each member of the team stays in contact with the
nurse case manger regarding individual assignments.
• Ideally team meetings are held daily or every other
day

45. • CPCs can be standardised because they are intended
to be used with uncomplicated cases
• A CPC can be viewed as protocol for various clients
with problems for which a designated outcome can be
predicted

46. CHARACTERISTICS OF CPC
• Pathway is a projection of the client’s entire length of
treatment
• Includes detailing of interdisciplinary intervention or
processes and client outcomes each day from
admission to discharge
• Pathway may be extended to include transfer to home
care or another treatment facility

47. VARIANCES
DEFINITION
A variance is defined as an unexpected client response
that “falls off” the pathway, requiring separate
documentation and further investigation by the
interdisciplinary team.

48. CAUSES OF PATHWAY VARIANCE
• Client or family
• Caregivers
• Hospital
• Community
• Payer(including insurance companies, health
maintenance organisations, or managed care
organisations)

49. BENEFITS OF CPC
• Support the introduction of evidence based medicine
and use of clinical guidelines
• Support clinical effectiveness, risk management and
clinical audit
• Improve multidisciplinary communication, team
work and care planning
• Can support continuity and co-ordination of care
• Provide explicit and well defined standards of care

50. • Help to improve clinical outcomes
• Ensure quality of care and provide a means of
continuous quality improvement
• Help to improve communication between different
care sectors
• Disseminate accepted standards of care
• Provide baseline for future initiative
• Reduce costs by shortening hospital stays

51. DEMERITS OF CPC
• Adaptability-on complicated case CPC becomes large
and detailed, cumbersome and ineffective
• Crash action-changes from scheduled plan in a
timeline, crash action involving reprioritizing each
step
• Resource allocation-when resource don’t match CPC
map, CPC begins to unravel

54. CONCLUSION
Critical pathways are tools to achieve patient or
programme outcomes.
It is the process of team collaboration that ultimately
produce quality outcome
Case management is critical to the success of
pathways
By guiding pathway implementation and variance
analysis, case manger can assure value to patient
through out the continuum

55. THANKYOU........