There is
no doubt that the current healthcare delivery system is experiencing massive and
revolutionary changes. With the increased infiltration of managed
care and managed competition and the interest of consumers in quality,
safe, and cost-effective care, healthcare administrators, nursing executives in
particular, are pressured to seek intelligent changes to the way care is delivered.
Most healthcare institutions, whether acute, ambulatory, long term, or home care,
have undergone some sort of reengineering and redesign. Regardless of the setting,
case management
continues to be the best way to deliver high-quality, efficient, and cost-effective
care.
Case management delivery systems have been proven successful in various care settings
(Guiliano and Poirier, 1991; Zander,
1991, 1992; Hampton,
1993; Tahan and Cesta, 1995;
Cohen and Cesta, 1997). They rely
heavily on case management
plans (CMPs) that delineate the best/ideal practice. In this chapter
a 10-step process for developing these plans is discussed. The process provides
a template for healthcare professionals who are interested in implementing CMPs
and a step-by-step guide to developing them, with practical examples to simplify
the process.
Although CMPs are not new to many healthcare organizations across the continuum
of care, the lack of a deliberate and systematic process to develop
these plans holds these organizations back from creating timely and efficient
results. This chapter is highly beneficial for healthcare providers, case managers
in particular, who are involved in the development of CMPs. They may acquire new
knowledge and strategies to simplify the task of developing CMPs, or even choose
to implement the proposed process if they currently do not have a formal one in
place. OVERVIEW OF CASE MANAGEMENT PLANS
Similar to case management delivery systems, CMPs became
popular because of the economic and political characteristics and pressures of
the healthcare environment. Some of the driving forces of CMPs are as follows:
Increasingly complex
and costly innovations in healthcare technology and treatment options
Since
their inception, CMPs have been used as tools to define the standards of care
and practice and as guides for patient care activities for all members of the
healthcare team alike. Whatever they are called, "they define the optimal schedule
of key interventions done by the various disciplines [and providers] to achieve
desired patient outcomes for a particular diagnosis or procedure" (Dykes,
1998, p. xiii). They are systematically developed as statements, guidelines,
and strategies for patient care management. CMPs are important tools developed
to assist providers in delineating the desired sequence of interventions and treatments
and in making decisions about appropriate and necessary interventions that effectively
address particular clinical situations. They usually incorporate the best scientific
evidence of effectiveness with expert opinion and recommendations of governmental,
professional, or specialty organizations.
CMPs have been in use for over 50 years; however, they have
been known as practice
guidelines (PGs) and were originally developed by physician groups
mainly for malpractice and risk
management purposes. The label case management
plans has only been popular for the past 2 decades, after the discipline
of nursing introduced the use of clinical
pathways as a strategy to address the nursing shortage of the 1980s.
With the demand for quality and safe healthcare services, the Agency for Healthcare
Research and Quality (AHRQ), formerly known as the Agency for Health Care Policy
and Research (AHCPR), advocated for the development and implementation of PGs
as a strategy for quality
improvement and evidence-based practice. This took place in the late
1980s and is still a major focus for AHRQ today; in fact, the agency has developed
and published multiple PGs and has made them available to healthcare organizations
free of charge.
This development has encouraged healthcare providers of different disciplines
and specialties to implement the AHRQ's guidelines in their practice. However,
because of the complexity of the guidelines, it was essential for AHRQ to pursue
other strategies for implementation, among which is the development of clinical
pathways/CMPs. This resulted in a shift in focus of the nursing clinical pathways
to interdisciplinary plans as we know them today. Because of this development,
CMPs and PGs should not be used interchangeably as they are not one and the same.
There exists some differences between the two and these are presented in Box
1.
The format of the CMPs is basically known as a "time-task" matrix that applies
either an abbreviated, one-page version or a comprehensive, detailed booklet (Tahan
and Cesta, 1995; Cohen and Cesta,
1997). CMPs have been developed based on the Gantt chart process and design.
They are available in paper or electronic form. However, their purposes, the way
they are used, and the process in which they are developed are approximately the
same (Thompson et al, 1991; Ferguson,
1993; Katterhagen and Patton, 1993;
Esler et al, 1994; Bozzuto
and Farrell, 1995; Hydo, 1995;
Ignatavicius, 1995; Ignatavicius
and Hausman, 1995; Meister et al,
1995).
CMPs are labeled differently in different institutions. Some are copyrighted,
such as CareMaps; some are not, such as multidisciplinary
action plans (MAPs). Examples of CMPs include critical path, anticipated
recovery path, clinical pathway, care guide, collaborative plan, coordinated plan,
integrated plan of care, or action plan. Throughout this chapter, these plans
will be referred to by using the generic term case management
plan. Case Manager's Tip 1 lists
the characteristics and benefits of CMPs.
The use of CMPs has created a multitude of advantages. Among the most important
are cost-effectiveness and reduction in lengths
of stay, readmissions to acute care settings, or home care visits;
consistency and standardization in care provision; implementation of best practices
and evidence-based treatment options; improved quality of care and customer satisfaction;
better allocation of resources and coordination of services that result in eliminating
redundancy, fragmentation, and duplication of care activities; clearly defined
plans of care and delineation of responsibilities; and improved communication
systems among the various disciplines and providers (Guiliano
and Poirier, 1991; Zander, 1991;
Ignatavicius, 1995; Ignatavicius
and Hausman, 1995; Tahan and Cesta,
1995; Cohen and Cesta, 1997).
TYPES OF CASE MANAGEMENT PLANS
CMPs link the processes and outcomes
of care. They are used as structured and formal plans that delineate the delivery
and management of patient care services and outcomes. They also are used to identify
best practices, standardize care activities, promote consistency and continuity
in practice patterns across providers and levels of care, enhance interdisciplinary
collaboration and a seamless approach to patient care delivery, and provide a
mechanism for measuring outcomes of care and addressing variances and deviations
from the standards. Healthcare organizations have designed and implemented many
different types of CMPs (Box 2). Some of
the plans include more details than others, some are multipurpose, and some may
address the responsibilities of multiple disciplines and providers.
Generally, there are three main areas of focus when CMPs are developed and implemented.
These are as follows:
To standardize old or
current practice; that is, to ensure consistency and continuity in care delivery,
services, among providers, and across settings. CMPs are developed for this
purpose when there are no other innovations, knowledge, or better ways/ideal
practices for the provision of care.
To implement evidence-based
practice or state-of-the-science care; that is, to change the current methods
and strategies of care delivery and management through the use of knowledge
gained from outcomes of research and clinical trials. CMPs are developed for
this purpose when the latest research outcomes about new treatments and interventions
have proven to be more beneficial to patients and cost-effective.
To innovate and develop
new practices; that is, to implement new strategies, treatments, and interventions
where there are no known ideal or evidence-based practices. CMPs are developed
for this purpose when experts in an organization are interested in testing
different treatment options that are still considered to be controversial
or have not been tested before. Such CMPs usually result in identifying ideal
and evidence-based practices after the period of experimentation is concluded.
Issue-Specific
Recommendations Issue-specific recommendations are statements of care
and decisions and are usually limited to clinical situations in their format and
content. They also are clear, concise, and direct to the point. They tend not
to address the total aspects of care of a patient with a specific diagnosis but
rather an individual aspect or a related process of care, such as prescribing
medications for a patient with pneumonia (Box
3). In addition, they identify the role of a particular discipline, and in
that regard they define the responsibility of a specific care provider to the
clinical situation they address. For example, an issue-specific recommendation
regarding the discharge of patients who are receiving intravenous (IV) antibiotics
while hospitalized and who are known to be IV drug users may indicate that the
prescriber of care and treatments (e.g., physician, nurse practitioner) should
switch an IV antibiotic to its oral form before these patients' discharge from
the hospital. Another example is the need to measure the temperature of a febrile
patient rectally, or to send a blood specimen for microbiology/bacteriology testing
when the patient's temperature is greater than or equal to 103.5°F.
Issue-specific recommendations may stand alone as policy statements
or be part of the standard of care. Sometimes they are incorporated in the CMPs
to enhance quality and safe practice, prevent errors and medical litigation, and
promote adherence to the standards of accreditation and regulatory agencies. Issue-specific
recommendations are not as popular today; however, healthcare providers used to
develop and implement them more often before the advent of other more detailed
types of CMPs such as clinical pathways, algorithms,
and MAPs. Healthcare providers have used them to proactively delineate the responsibilities
and practices of the various disciplines involved in patient care and in specific
situations.
Algorithms Algorithms are problem-based procedures of care that
are developed by healthcare providers as consensus statements to delineate the
process(es) of caring for a patient with a specific medical condition or health
problem such as asthma (Figure 1). They
include a step-by-step guide to the care of patients and usually focus on the
clinical decision-making process regarding the patient's assessment and the required
diagnostic and therapeutic interventions and treatments. Usually, algorithms are
written in an "if … then" style (Cole
and Houston, 1999); however, the use of the "if … then" may not always
be explicit. Sometimes, arrows (indicating direction) and boxes (containing the
recommended care options) are used instead of "if … then," such as in the
example presented in Figure 1. Regardless
of the method used, algorithms apply a stepwise format that is systematic, chronological,
and outcomes driven.
Algorithms focus on the logical progression of intervention
options that are driven by the patient's response to treatment (Cole
and Houston, 1999) and aim at resolving the patient's problem. They are rulesbased
and leave little room for decision making and judgment because they are prospectively
developed as explicit interventions for managing specific conditions. These decisions
are specified in the content of the algorithm and follow the style described above.
As with CMPs, it is appropriate to deviate from the algorithm; however, the healthcare
provider deviating from the plan must have a logical reason for such actions and
must document the rationale of the deviation in the patient's medical record.
Sometimes documentation flowsheets/tools (Figure
2) are developed in conjunction with the algorithms to simplify the process
of patient care provision and documentation. In this case the algorithm and the
documentation tool are implemented as a package; one is not used in the clinical
setting without the other.
Protocols Protocols are similar to algorithms in their systematic
and logical progression format. They are usually specific to a patient's problem
and mainly used as integral components of clinical trials and research. They also
are used as formal guides to delineate all of the steps for the application of
a particular procedure or intervention (Cole
and Houston, 1999). In addition, protocols provide a standardized approach
to meeting desired outcomes of care. An example is an acute coronary syndromes
protocol that classifies chest pain and angina into different levels of intensity
or seriousness and details the appropriate and necessary treatments/interventions
for each level. In this example the protocol guides the healthcare providers in
the assessment, diagnosis, and treatment of chest pain.
Preprinted Order Sets Preprinted order sets are prospectively prepared by
one or more disciplines or healthcare providers to delineate a standardized process
for the diagnosis and treatment of patients with particular problems. These orders
focus mainly on medical/physicians' practice. However, they may also address the
responsibilities and expectations of other providers, including nurses and other
allied health professionals (e.g., social workers, physical therapists). They
are developed based on research outcomes and the latest recommendations of professional
societies such as the American Heart Association. The purposes of preprinted order
sets are to standardize and expedite care, provide evidence-based care, and prevent
variation in the practice patterns of providers. Sometimes preprinted order sets
are used alone or in conjunction with CMPs. They are a positive way of increasing
physician buy-in to CMPs.
Guidelines Guidelinesare statements of specific recommendations for the care of
patients with a particular health problem such as heart failure. They are written
in a narrative or outline format to provide guidance for the care and management
of patients, especially in the areas of diagnostic and therapeutic tests and procedures.
Unlike issue-specific recommendations, they make reference to time and may include
specific timeframes for the implementation of designated actions or the achievement
of certain outcomes. Guidelines have been used in anesthesia for many decades;
however, they only became popular in other specialties and disciplines with the
advent of case management and managed care. They are thought to reduce legal risk
and are adopted by healthcare organizations and professional societies for that
purpose.
Guidelines are systematically developed recommendations for
care to assist healthcare providers in making decisions regarding the appropriateness
and necessity of care and services. Similar to the other types of CMPs, guidelines
provide practitioners with advice that is based on expert opinion, consensus statements,
and research outcomes. Moreover, they intend to reduce practice variations and
improve patient care outcomes (Figure 3).
Today guidelines are developed and advocated for either internally in a healthcare
organization or nationally by federal agencies such as the AHRQ and professional
organizations such as the American Medical Association. They may be broad or specific
depending on their source of origin. Those developed or adopted by a healthcare
organization tend to be based on the nationally acceptable guidelines and more
specific in content and timeframes, taking into consideration the systems and
process of care present in the particular organization.
Clinical/Critical Pathways Clinical/critical pathways are specific guidelines
of care developed to delineate the contributions and responsibilities of the various
disciplines and specialists for the care of specific patient populations. They
are problem-based and discipline-focused in content (Figure
4). The clinical/critical pathway format is based on the Gantt chart used
by engineers and architects. Karen Zander was the first to use clinical pathways
at the New England Medical Center in Boston, Massachusetts, in the mid-1980s.
They were called CareMaps then, applied a one-page format, and focused almost
exclusively on nursing. They were originally used as a strategy to address the
nursing shortage; however, they grew to become of multidisciplinary focus and
today are adopted for use by all disciplines and providers.
Similar to the other types of CMPs, clinical/critical pathways are developed based
on national standards and research outcomes and are best used for evidence-based
practice. However, they differ from the other types of CMPs, except MAPs, in that
they include specific timeframes for all of the recommended activities. They also
are used as cost-effective tools for the delineation of key and critical resources
and activities; to specify the order, timeliness, and progression of these activities;
and to provide a mechanism for the evaluation of patient care outcomes and for
meeting the desired outcomes. Multidisciplinary Action Plans MAPs (Figure 5)
are similar to clinical pathways in their purpose, focus, and process of development.
However, they are more detailed, several pages in length (sometimes they are developed
in a booklet format), allow room for documentation, and have medical orders embedded
in them. In addition, they provide evidence of a collaborative and seamless approach
to care for accreditation agencies and result in opening the lines of communication
among the various providers.
MAPs specify both the actions/interventions necessary for the
care of patients and the related and expected outcomes. They detail outcomes in
relation to progression toward recovery; that is, the outcomes follow a specific
sequence that is temporal and allows practitioners to easily evaluate the patient's
condition and progress in relation to recovery or problem resolution and to determine
the appropriate next step in care. This is done by prospectively delineating the
intermediate outcomes that must be met first so that the care and the patient
can progress in the desired direction. The outcomes are presented in the MAPs
using specific timeframes similar to those applied for the interventions and treatments.
This characteristic, as it pertains to outcomes, tends to be lacking in clinical/critical
pathways. Another differentiating factor between MAPs and clinical pathways is
that MAPs may include algorithms and preprinted order sets, whereas pathways usually
do not.
PROCESS OF DEVELOPING CASE MANAGEMENT PLANS
CMPs are developed best through an interdisciplinary
team that is granted the authority and responsibility by a higher administrative
structure, usually a steering committee charged with implementing case management
systems, to develop a specific plan for a particular diagnosis or procedure. The
interdisciplinary team is given the responsibility of developing the actual content
of the plan. The steering committee, however, provides the team with ongoing expert
and administrative support throughout the process.
Team members meet numerous times to discuss and develop the CMP. Sometimes they
work individually in between meetings. The length of time needed for the development
and completion of one CMP usually depends on the complexity of the diagnosis or
procedure; the number of physicians and practitioners who will use the plan; the
extent of the disagreements among physicians regarding the content of the plan
that may arise while attempting to build consensus;
the number of disciplines involved; the experience of the team members involved
in the process; the availability of team members, their commitment, their productivity,
and how well they can work together (i.e., group dynamics); and the presence or
absence of a support person or an expert in CMP development. One CMP may take
as long as 6 to 9 months for completion, particularly if the team is developing
a CMP for the first time, or as little as a few weeks if team members are well
experienced in the process and the topic of the plan is less controversial.
Steering Committee The steering committee is composed of professionals
who hold executive-level positions in the organization. The departments represented
on the steering committee may include, depending on the sophistication of the
healthcare organization, operations, finance/cost accounting, marketing, nursing/patient
care services, information systems, medical records, legal and risk
management, quality improvement and utilization
management, managed care and case management, data management, research,
and other ancillary
services as deemed necessary. Members of the steering committee may
be the high-ranking officers of each of these departments or their designee. It
is not always necessary to have a representative from each of these departments.
Some institutions may choose not to create a new standalone committee for this
purpose. Responsibilities of a steering committee, in this case, may be added
to a preexisting committee such as a quality council or a length-of-stay or cost-reduction
taskforce.
The major role of the steering committee is to put together a strategic plan for
the implementation of case management systems. This plan describes the processes
of training and educating those involved in the process; selecting and prioritizing
the diagnoses and procedures for which CMPs are to be developed; and providing
support for the teams charged with developing CMPs. Members of the steering committee
provide leadership, support, and direction for the development, implementation,
and evaluation of the case management system.
Most institutions have established a standardized process for the development
of CMPs. The steering committee is responsible for the development of this process.
Having an established formal process is important because it provides the interdisciplinary
team with the foundation for successful development and implementation of CMPs,
simplifies the work, and lays out the expectations. An ideal process is a simple
one that clearly identifies the steps in a systematic way and makes it easier
for the team to follow.
This chapter includes an example of such processes (Figure
6) for healthcare administrators to adapt to their organizations and adjust
as needed. This example follows a 10-step process that differentiates between
the work and responsibilities of the steering committee and the interdisciplinary
team.
The steering committee is responsible for the first four steps because they require
higher administrative authority in decision making. They are related to the logistics
of case management systems and plans and are part of the overall case management
implementation plan put together by the steering committee and approved by key
executive personnel in the institution. The remaining six steps are the responsibility
of the interdisciplinary team and address the actual work of the team and the
creation of the CMP.
Step 1: Design the Format of the Plan Deciding on the format is crucial, because the format
guides the development of the content of the plan (Case
Manager's Tip 2). The format should be made easy for all healthcare professionals
to follow and use. This step is integral to the establishment of case management
systems because it affects clinical practice and other care activities and processes
(e.g., documentation, performance
improvement processes, coding of the medical record, presentation of
the standards of care and practice).
The CMP should be designed in such a way that includes the various elements of
patient care (Box 4) (Ferguson,
1993; Ignatavicius and Hausman, 1995).
Some of these elements are related to the medical/ surgical care of the patient,
whereas others are nursing in nature. In addition, there may be elements related
to support or administrative services. Specific sections of the CMP should be
allotted to quality indicators, outcome measures of care, variances
tracking, and data collection. The number of the different care elements for each
CMP depends on the diagnosis or surgical procedure addressed. For example, a plan
for chest pain evaluation may include a pain management section but not occupational
therapy. However, speech pathology and physical and occupational therapy are important
when addressing a stroke CMP. A CMP to be used in a subacute care facility designated
for ventilator-dependent patients should always include a respiratory care section
that stresses the institution's protocol for weaning patients off mechanical ventilation.
The final format of the CMP (see Appendix 1 for an
example) should be presented to the institutional medical records committee, legal/risk
management department, and medical board for review and approval before it is
made official. A decision regarding the format should be in place before authorizing
any interdisciplinary team to start working on a CMP. The approved format becomes
the desired CMP's template that is followed by all interdisciplinary teams to
maintain consistency and uniformity of plans. The format also provides the framework
based on which the team can construct the content details of the CMP. The steering
committee then develops guidelines for the use of the template/final format of
the CMP. The guidelines explain in detail how the template should be followed
or used, the definitions of each of the care elements, and examples of the various
patient care activities that could be listed under each care element (Box
5). This is important because it maintains continuity and consistency of CMPs
across the various interdisciplinary teams. When a team is established, a copy
of the template/format and a copy of the guidelines should be presented to and
discussed with the team members. Step 2: Identify/Select Target Population The mechanism for selecting target populations can
be done at any time during the design phase of the CMP format. The steering committee
studies the patient populations/groups served by the institution. It then selects
the groups that need improvement regarding cost and quality, present a risk for
financial loss, or are a potential for revenue.
There are several criteria that must be considered when selecting
target populations for which to develop CMPs. These include volume of the patient
group, cost of care, complexity of care needed, institutional length of stay compared
with other benchmarks,
variations in practice patterns, the need for multiple services/care settings
or providers, feasibility of developing the plan, potential revenue (i.e., control
of resources, fragmentation and duplication of care), opportunity for improvement
in quality of care and outcomes, reports from payer groups, problem-prone/high-risk
diagnoses or procedures, and results of internal and external quality management
monitoring (Ignatavicius and Hausman,
1995; Tahan and Cesta, 1995;
Cohen and Cesta, 1997).
It is important to evaluate the number of patients seen in
a particular diagnosis-related
group (DRG) when selecting a target population. The decision of which
DRG should be targeted is made based on the number of patients seen in a particular
DRG during a whole year. The larger the number of patients seen, the better the
opportunities for improvement. The established CMP will then be applied to a larger
population, which maximizes the benefit.
Because a DRG is too broad and may include several procedures that require different
resources, whereas the International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM)
is very specific, evaluation and analysis of patient populations should be made
at the ICD-9-CM code level. Consider DRG 112 (percutaneous cardiovascular procedures)
as an example. It includes several different procedures, with each designated
a separate ICD-9-CM code (Table 1) (St.
Anthony Publishing, 1992). The treatment plans for each of these procedures
are different—cardiac catheterization is a diagnostic procedure, whereas
angioplasty is a therapeutic procedure, and electrophysiological cardiac stimulation
is a diagnostic procedure but very different than catheterization, which makes
developing a CMP for DRG 112 more difficult. However, developing a separate CMP
for each procedure/ICD-9-CM code is more feasible and desirable. As a result,
it is better to consider developing a separate CMP for each ICD-9-CM code than
for the DRG.
Another example is DRG 96: bronchitis and asthma, age greater
than 17 years with complications
and comorbidities
(Table 2). There are major differences
between treating these two disease entities. It is best to deal with this DRG
based on ICD-9-CM codes (St. Anthony
Publishing, 1992). Sometimes it is appropriate to combine two or more ICD-9-CM
codes in one CMP. For example, combining asthma ICD-9-CM codes 493.20, 493.21,
493.01, and 493.11 in one CMP that delineates the standard of care of adult asthma
is relevant because there exist minimal to no variations in the treatment of asthma
in the different ICD-9-CM codes. However, combining ICD-9-CM codes 493.20, 493.21
and 491.1, and 491.2 is not appropriate because treating asthma is different than
treating bronchitis, and the standard of care for both diagnoses cannot be combined
into one standard.
The volume of patients seen in one DRG should not be considered
in isolation from other measures, such as cost per case, cost per day, consumption
of resources (e.g., the number of x-ray examinations, blood tests, or electrocardiograms
in one hospitalization or episode of care), average length of stay, outcomes,
and profit and loss ratios. Patient populations that exert financial loss on the
institution are considered the best target for CMP development.
Table 3-3 is an example of one administrative report that can be used to identify
a target population. Examining the data presented, one can see that DRGs 88 and
127 have longer lengths of stay and at the same time have profit losses. Thus
considering the development of CMPs for these two DRGs is worthwhile because the
opportunities for improvement and profit are high. To address these two DRGs requires
the establishment of two different teams for CMP development because the DRGs
are related to two different services—pulmonary and cardiology.
Conversely, DRGs 90 and 143 are not a high priority for CMP development because
the length of stay is lower than that in comparable institutions and they are
financially profitable. The institution may decide to develop CMPs for these diagnoses
based on other factors and improvement efforts, such as quality of care, practice
patterns, and allocation and use of resources.
Deciding which CMPs must be developed is not always the decision of the steering
committee. Some healthcare organizations leave such decisions open and encourage
the various departments and specialties to decide on the topics that are appropriate
for them. Other organizations may purposefully leave such decisions to the clinicians
and address the development of CMPs as a department-based quality improvement
plan. In either case, the steering committee may institute the use of a communication
tool/form so that it is kept abreast of the developments in each department (Figure
7). The use of this tool is beneficial to the organization. It helps keep
the steering committee informed of the activities and improvements taking place
at the department level. It also ensures that the departments are kept focused
and on target and that their efforts are not being wasted. Furthermore, it allows
the steering committee to evaluate the level of responsibility, accountability,
and initiative assumed by the department. Step 3: Organize an Interdisciplinary Team Traditionally, members of the interdisciplinary team
were selected by the steering committee, and recommendations from department heads
were usually considered when organizing the team. Today, however, most healthcare
organizations defer this responsibility to the various departments and clinical
specialties. In this case, the departments and the steering committee communicate
constantly. The department may also seek the advice of the steering committee
when problems arise or challenging decisions need to be made. The selection of
members is based on their communication skills and ability to work in a team,
their clinical competence and past experiences, and their commitment to their
work. Becoming a member of an interdisciplinary team and contributing to the development
of processes that improve patient care can be a rewarding experience for staff
members.
Based on the type of the CMP to be developed, members from the various disciplines
involved in patient care are selected to serve on the team. It is important to
include all disciplines so that the completed plan is thorough and well written.
Every team should include representatives from various departments or disciplines
such as medicine (including house staff), nursing, case management, quality improvement
and utilization management,
social services, home care, and nutrition. Members from other departments may
participate on a consultation basis. These departments may include pharmacy, medical
records and coding, finance, patient representative, materials management, laboratory,
and radiology. Some departments may be represented as needed based on the diagnosis
being worked on. For example, representation from rehabilitation, occupational
therapy, and speech pathology is essential for a team working on a stroke CMP,
respiratory therapy for asthma, chronic obstructive pulmonary disease, or pneumonia
plans.
The interdisciplinary team should be moderate in size (i.e., 6 to 10 members).
A larger team reduces its productivity, increases the risk for disagreements,
and delays the process. The team is empowered by the steering committee to make
independent decisions. The steering committee may designate one of its members
to act as a sponsor for the team. The sponsor's role (Case
Manager's Tip 3) includes coaching the team through the process, removing
obstacles and answering unresolved questions, acting as a liaison between the
team and the steering committee, and overseeing the administrative activities
that keep the team functioning. In addition, it is important that the steering
committee appoint two members of the interdisciplinary team to act as the team
leader and the facilitator (Case Manager's
Tip 4). Most healthcare organizations designate a physician and a nurse to
assume these roles. These two members play an important role in keeping the work
of the team progressing and ensuring that the goals and objectives of the team
are met within the established timeframe. Some institutions may require the team
to present its recommended CMP before the steering committee when it is completed
and ready for implementation.
Direct care providers should be well represented on the team
as team members (Case Manager's Tip 5)
because they are instrumental in sharing their firsthand experiences with the
day-to-day patient care activities. To prevent physicians' resistance to the use
of CMPs, it is recommended that they be involved in the process from the beginning
and given the leader or co-leader role on the interdisciplinary team (Tahan
and Cesta, 1995; Cohen and Cesta,
1997). Past experiences show that physicians who participate on a team act
as champions in promoting case management systems and CMPs in their institutions
and continue to be the best supporters and sellers.
Step 4: Educate/Train the Team in the Process Before the team launches the development process for
a CMP, members should be trained in the process. Formal training must include
topics such as general overview of case management systems and plans; the process
of developing CMPs; the responsibilities of the team leader, facilitator, and
member; and tools and strategies for success. Examples of the work of other teams,
if they exist, should be shared (Ignatavicius
and Hausman, 1995; Tahan and Cesta,
1995; Cohen and Cesta, 1997).
It is in this forum that the expectations from the team, the administrative support
available to the team, and the role of the sponsor and the steering committee
as they relate to the role of the interdisciplinary team should be discussed.
The team should be given the opportunity to ask any questions or raise any concerns.
It should also be informed of the ongoing support of the steering committee throughout
the process. After completing the required training, the team starts its work
on the plan.
One may ask who prepares the steering committee regarding case management systems
and how members of the steering committee acquire their related knowledge. Most
healthcare organizations hire an outside consultant (an expert in case management
systems) to help and guide them through the process. The consultant plays an important
role in helping the steering committee develop the best case management system
for the organization. The consultant also develops an education packet specific
to the institution's policies, procedures, and operations to train members of
the steering committee and the interdisciplinary teams that will be developing
CMPs. Sometimes organizations may prefer to hire a full-time employee (instead
of a consultant) who is an expert in the area of case management to assume full
responsibility for the program. The employee is usually responsible for coordinating
all the activities of the program; educating committee members, interdisciplinary
team members, and staff; and acting in place of the consultant.
Developing the Plan's Content Step 5: Examine the Current Practice This step represents the start of the work on the actual
content of the plan. The team members usually begin with brainstorming regarding
the care of a patient. Members are asked to concentrate on the routine rather
than the exception (i.e., the normal recovering patient and not exceptions or
extraneous situations) because exceptional patients usually represent a small
number of cases. During brainstorming, members attempt to list any quality barriers
regarding patient care and any experienced delays in the past. Discussing the
quality barriers helps members better understand the current situation and identify
the improvement efforts the CMP will address.
After brainstorming is exhausted, team members move on to developing a flow diagram
for the current process. A flow diagram that highlights the most important steps
in the process of caring for a patient is recommended to prevent the team from
getting bogged down with the unnecessary details. The flow diagram (see Section
4, Chapter 1, Figure 1-1, for an example of a flow diagram)
should reflect the projected care of the patient from admission until discharge
and in some cases until after discharge or from the beginning to the end of the
care episode.
There are several ways to examine current practice patterns. The two most important
ones are review of medical records and interviews of care providers. In medical
record reviews, members concentrate on the critical elements of care presented
in Box 4, such as assessment, tests and
procedures, treatments, consultation and referrals, care facilitation and coordination,
medications, IV therapy, activity level, nutrition, patient and family teaching,
wound care, physical and occupational therapy, pain management, outcome
indicators and projected desired responses to treatment, and discharge
planning. Data collection regarding the critical elements and the associated
timeframes of delivery of patient care activities is essential in the development
of CMPs. Mostly, tools to simplify and standardize the process of collecting data
are developed by the team members before starting the data collection process.
Particular attention is given to the care activities considered as critical milestones
of care or trigger points for a change in the treatment plan. For example, it
is important to collect data about when an IV antibiotic is switched to its oral
form during the hospitalization of a patient with pneumonia or when an IV corticosteroid
is switched to an oral form while caring for a patient with asthma. These milestones
are important because they affect the length of stay and are considered outcome
measures or quality
indicators. It is recommended that a thorough chart review be done
regarding the most significant care activities that are required for a case type,
with particular evaluation of their timeframes for completion. For example, caring
for a patient hospitalized for a coronary intervention procedure may require healthcare
professionals (physicians, nurses, and others) to ensure the successful completion
of several different care activities (Box 6)
preprocedure, intraprocedure, postprocedure, and at the time of discharge. These
activities, as specified in Box 4, should
be the center of medical record reviews when developing a CMP for coronary interventions.
Practice patterns of individual physicians should be assessed for variables such
as length of stay and cost per case (Table
4) by examining the effect of starting time of antibiotic therapy on length
of stay (Figure 8) or by reviewing the
use of resources per case (e.g., counting the number of electrocardiograms, x-ray
examinations, scans, blood tests). In the example seen in Table
4, physician B has the lowest average length of stay and the lowest cost per
case. This physician appears to be providing care differently from the others.
Medical records for this physician's patients must be reviewed and compared with
other physicians' records to identify differences and determine appropriate practice
patterns for the CMP.
Using the example in Figure 8, one can
see that the earlier the first dose of antibiotic is started in a pneumonia patient,
the shorter the average length of stay will be. Based on this conclusion, the
interdisciplinary team might recommend that the antibiotic to be used to treat
pneumonia should be started as early as the time of admission. This recommendation
should be reflected in the timeline of the CMP for pneumonia.
After completing the medical record reviews, team members interview representatives
of the healthcare team who provide care for the patient population in question.
This includes physicians, house staff, nurses who provide direct patient care,
and ancillary and professional staff. Similar to the medical record reviews, the
interviews concentrate on the critical elements of care and their attached timeframes.
Other important documents available in the organization are also reviewed by the
team and are studied carefully for their relation to and impact on the delivery
of care. These may include any data reports on file in the institution (e.g.,
utilization, financial, quality
assurance and improvement, and medical record reviews), the standards
of care and practice, the preprinted physician orders, protocols, and guidelines
(Ignatavicius and Hausman, 1995;
Tahan and Cesta, 1995; Cohen
and Cesta, 1997).
As members of the CMP development team review the practice patterns of providers
and a sample of the medical records, they may find that there is no consistency
in treatment plans. An important strategy to address such situations is a review
and evaluation of related literature (see step 6 below). This helps the team to
decide on which plan of care to adopt. However, the literature may not always
provide the answer. In this case the team's next strategy is to pursue consensus
building on a desirable treatment approach with key and influential providers
in the organization to resolve this dilemma. Situations such as this are common,
especially in areas in which treatment options are controversial, no research
is available to support one type of treatment versus another, or no national standards/recommendations
are made by professional and specialty organizations. When the CMP development
team encounters such a situation, it must look at it as an opportunity for a change
in practice and for innovation; that is, developing new care methods and treatment
options. The team must then test the new methods and evaluate their outcomes.
If the outcomes achieved are not desirable, the new methods must be altered as
indicated and then retested. If found to be favorable, they should be adopted
on a larger scale as the normal practice and standard of care. Such a process
results in the development of new ideal/best practices in areas that otherwise
might be considered controversial.
Step 6: Review the Available Literature A thorough review and evaluation of the literature
is essential because it raises awareness of team members to the latest trends
and technology in patient care. The available research should be studied carefully
and used to validate the recommendations made in the CMP. This creates an opportunity
to provide patient care that is research/evidence-based. Without consideration
of the relevant outcomes of research and clinical trials, the CMP developed becomes
specific to the healthcare organization and may not reflect the ideal/best practice,
or the state-of-the science care (Janken,
Grubbs, and Haldeman, 1999). To promote the development of a CMP that is evidence
based, research utilization methodologies must be incorporated in the process
of developing the content of the plan. This is achieved through a critical review,
analysis, and evaluation of the literature. Therefore it is important to merge
the processes of CMP development and research utilization. This can be achieved
by applying the following steps (Janken,
Grubbs, and Haldeman, 1999):
Review the research literature
as it pertains to the topic of the CMP or the clinical practice problems.
Evaluate and critique
the research for its strengths and weaknesses.
Evaluate the appropriateness
of the research outcomes for application in practice.
Apply the outcomes that
are considered ready for implementation in practice by incorporating them
as an integral part (i.e., care activities and interventions) of the content
of the CMP.
Review
of the literature should also include an examination of any published related
quality improvement efforts, CMPs, and existing standards of care that are developed
by professional organizations such as the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), physician groups and societies such as the American
Medical Association, nursing organizations such as the American Nurses Association,
or governmental agencies such as the AHRQ, formerly known as the AHCPR. Other
essential literature to be used in the development of CMPs is the literature on
transitional planning
and managed care guidelines. It is necessary to examine transitional planning
to obtain information on the latest regulations about the various care settings
across the continuum and their related admission and discharge criteria and associated
reimbursement
methods. The managed care literature relates to the Milliman & Robertson Guidelines
(Schibanoff, 1999) and InterQual
criteria (InterQual, Inc, 1998).
These guidelines play an essential role in ensuring that the CMPs developed adhere
to the managed care reimbursement standards by including appropriate interventions
and care progression activities and reinforcing the provision of quality care
and services.
Step 7: Determine the Length of the Plan The length of the CMP is based on several factors,
including institutional administrative reports regarding the average length of
stay and reports of length of stay per physician, the DRG's length of stay for
Medicare
and non-Medicare populations, managed care contracts and their respective organizations,
variations in practice patterns as they relate to the length of stay, physician
preference, reimbursement reports, benchmarks from other healthcare organizations,
and improvement targets (Ferguson, 1993;
Esler et al, 1994; Bozzuto
and Farrell, 1995; Ignatavicius,
1995; Ignatavicius and Hausman, 1995;
Tahan and Cesta, 1995; Cohen
and Cesta, 1997). The team should study the length of stay issue very carefully,
and it should seek the steering committee's support and guidance as needed. The
length of the CMP, as decided by the team, should be within the reimbursable range
and lower than the institution's current average length of stay for that particular
diagnosis or DRG. Also, it is crucial that improvement targets regarding length
of stay, mostly decided by the steering committee, are made known to the interdisciplinary
team before launching the development process of the CMP. Step 8: Write the Content of the Plan This step involves compiling all of the data collected
in the previous steps. Representatives from each department are asked to write
a draft of their respective part in the provision of care following the approved
format of the plan and based on the results of the data collected from chart reviews,
interviews, and review and evaluation of the literature and research outcomes.
All drafts are then put together on one form to be discussed and finalized by
the team members.
The content of the plan should reflect the state-of-the-science care and the ideal/best
practice that were agreed on by the team, in realistic timeframes. For example,
expecting to complete an echocardiography by day 2 of the hospitalization of a
chest pain patient, knowing that the system requires a turnaround time of 72 hours
from ordering to completion, is not realistic. Such an unrealistic expectation
will result in delays in care, compared with the plan, every time a patient with
chest pain is admitted for treatment. However, the team may make a recommendation
to the steering committee that the process for completing an echocardiography
in 72 hours be evaluated so that a 2-day turnaround is possible. It then becomes
the responsibility of the steering committee to make a final decision regarding
the timeframe.
When the team finishes the plan, it should be circulated for
review by a group of physicians, nursing leaders, ancillary department heads,
and support services involved in the care of the specific patient population.
The CMP also must be sent to the pharmacy department to review whether the medications
selected are cost-effective and to the coding division of the medical records
department for a review of word choices that may enhance coding and improve reimbursement.
This review must be done before concluding the content of the plan, and it could
be done earlier in the process.
The CMP will then undergo a final review by the team with regard to the recommendations
of the reviewers. The final draft of the plan is then presented to the steering
committee for approval. The steering committee may suggest the use of an approval
form (Figure 9). In case such a form is
used, the multidisciplinary development team will be required to submit the final
draft of the CMP attached to the approval form for the steering committee review
and approval. The use of this form is important for record keeping with regard
to the review and approval process. The team clarifies any questions asked and
presents the reasons a particular practice pattern was recommended. Finally, the
CMP is put into practice.
Step 9: Conduct a Pilot Study of the Plan In this step the team implements the use of the CMP.
Training and education regarding the CMP for all healthcare providers involved
in the particular specialty or diagnosis should be completed before implementation
of the plan (Box 7). The CMP is then evaluated
for quality, feasibility of use, appropriateness of timeline and clinical activities
and interventions, length of stay, any delays or variations in care, practice
patterns of physicians and other care providers, and compliance. For the CMPs
that include state-of-the-science care and are considered research/evidence-based,
it is important for the team to evaluate the appropriateness of such content to
the patient population addressed in the CMP. Therefore it is necessary for the
team to evaluate the patient outcomes achieved by the CMP to ensure that they
are consistent with those reported in the original research or clinical trials.
If outcomes are found to be consistent, the CMP is then finalized as the standard
of care. However, if the outcomes are not similar, the team must reexamine the
interventions, evaluate the possible causes, and revise the content accordingly.
Such process must continue until the team is pleased with the results.
The CMP is piloted on a group of patients. In addition to evaluating the content
of the CMP, it is as important to survey the providers using the CMP for their
perception and satisfaction with its use. Figure
10 contains an example of a tool that can be used for this purpose. The results
of the pilot are then analyzed and discussed by the interdisciplinary team, and
revisions are made accordingly. The plan is then printed in the final version
for official use.
Step 10: Standardize/Normalize the Plan After completing the pilot study of the CMP and making
the required changes, the interdisciplinary team meets to develop policies and
procedures regarding the use of the plan. It should be made clear to all involved
healthcare professionals that the CMP represents the standard of care for that
particular population and should be followed when caring for the patient. It should
also be made clear that some patients might not fit the CMP and that it is appropriate
not to use the CMP in these situations (Case
Manager's Tip 6). It is common knowledge that CMPs do not apply to every type
of patient because they are developed based on the care of the average patient
(i.e., for 80% of the population) and not the exceptional cases. The final plan
is then added to the master manual of CMPs and circulated in the final format
to key people in the institution. The plan can be shared with various healthcare
providers in different forums such as grand rounds, newsletters, and administrative
and departmental meetings.
Policies and procedures on the use of CMPs, particularly documentation
of patient progress and variances, what to do when a patient does not fit the
CMP, and why it is important to individualize the CMP, are extremely important
and should be in place before implementing the use of CMPs. Such policies and
procedures serve as a guide and reference for any healthcare practitioner required
to use the CMPs.
PATIENT AND FAMILY CASE MANAGEMENT
PLANS
The design and use of CMPs is not limited to those
used by providers of care. Patient- and family-focused plans (for use by the lay
public) are popular today and are viewed as essential tools for patient/family
education about necessary treatments and care expectations. Patient and family
CMPs have become an integral component of case management systems. They are developed
as an essential progression of provider's CMPs and packaged together as a set
of plans that delineate the care of patients for both providers and consumers
alike.
Patient and family CMPs (Figure 11) are
defined as tools for educating the consumers of healthcare. They are patterned
after provider's CMPs and include basic information about the plan of care using
lay terminology, a language that patients and their families are able to understand
easily. Similar to provider's CMPs, they are diagnosis, procedure, or problem
specific; apply a timeline that is appropriate to the care setting they are used
in; and may follow a "time-task" matrix format. Furthermore they are written in
simple language (i.e., fourth to sixth grade reading level), concise, clear, and
characterized by the use of graphics and clip art. The graphics are pictures and
symbols used to make the plan more valuable, meaningful, attractive, and interesting
to read and use for patients. This is especially important because the plans are
directed to those without a medical background.
Patient and family CMPs are used to facilitate the following:
Educate patients and
their families about the normal course of treatment
Communicate to patients
and their families realistic expectations of the care and their timeline
Answer patients' and
families' questions
Enhance informed decision
making
Empower patients and
enhance their ability to assume more responsibility toward their care
Reinforce the role patients
and their families play in their care as integral members of the healthcare
team (Parker, 1999)
Patient
care plans can also be used as a tool for contract development between a provider
and a patient/ family. The expected outcomes of the plan are reviewed with the
patient and family and given to them in writing. The patient is then asked to
sign the plan, indicating that he or she agrees with it. In this way the contract
is developed between patient and provider and the patient becomes an active member
of the care team, participating in the development of the goals of care and the
expected outcomes and timeframes for achieving the goals.
The plan is reviewed with the patient and family at the appropriate time intervals;
that is, at times related to milestones of treatments, as specific outcomes are
achieved, or when decisions about treatment options are needed. For example, if
the plan consists of daily goals of care, then it should be reviewed with the
patient on a daily basis. If the patient achieves a goal sooner than expected,
then that achievement should be reviewed and the plan altered accordingly.
Patient and family CMPs are developed by a multidisciplinary team of providers
that represent the various specialties and disciplines involved in the care of
patients with a particular diagnosis. They are also reviewed and approved by a
steering committee similar to the provider-based CMPs. The process of developing
patient and family CMPs differs from that of provider's CMPs in that the development
team includes a patient advocate or representative whose role is to bring the
perspective of patients to the development process. The process is similar to
the way patient education materials are developed. In fact, most institutions
integrate the patient's CMP development team with the patient and family education
committee because of their common aspects and objectives. The skills, knowledge,
and expertise of members of the patient/family education committee make it easier
for the team to develop patient-focused CMPs. They also enhance writing plans
that are personal and conversational in nature. For example, it is common to see
patient and family CMPs with phrases such as "you will need to," "you will be
asked to," "your physician," or "your nurse." Another characteristic related to
style is the use of words that are nonmedical in nature, such as "walk" instead
of "ambulate," "going home" instead of "discharge," or "low blood sugar" instead
of "hypoglycemia."
The type and number of care elements included in a patient and family CMP varies
based on the diagnosis or procedure it addresses. Usually the number is kept to
a minimum; that is, limited to those that are essential. The most common elements
are tests and procedures, activity and exercise, diet, medications, pain control,
teaching and instructions, and preparing to go home. The content included in these
elements relates to what is predictable, essential, and standard. "Less is more"
is the rule of thumb. It is important to focus on activities the patient is able
to handle and control. Refraining from the use of content that patients are unable
to comprehend is desirable because it may make them feel frustrated, anxious,
or fearful. STRATEGIES FOR PHYSICIAN PARTICIPATION AND BUY-IN
Physicians play a key role in the success of the interdisciplinary
team charged with developing a CMP for a particular diagnosis or procedure. Physician
participation in developing the plan is integral to improving consistency (i.e.,
eliminating variations in physician practice patterns) in the care of patients
with similar diagnoses who are cared for by different physicians. Obtaining physician
support is a prerequisite to achieving the identified goals of the team. Physician
buy-in to the use of CMPs before their development and implementation is a key
to compliance in their use afterward. Case
Manager's Tip 7 lists some strategies that can be employed to obtain physicians'
buy-in and increase their participation in the interdisciplinary teams for CMP
development. ORGANIZING THE WORK OF THE INTERDISCIPLINARY
TEAM
The steering committee may provide the interdisciplinary
team members with policy/guidelines that define what is expected from the team
and how the work should progress in each meeting. These guidelines are used to
facilitate, simplify, and expedite the process of developing and implementing
CMPs (Case Manager's Tip 8). The steering
committee assigns the team's leader and facilitator before the team's first meeting.
These two members are specially trained to assume these roles. Interdisciplinary
team members are also trained in the roles they play. Preparing all members of
the team, including the facilitator and leader, is important because training
improves the team's productivity and increases members' skills in teamwork and
CMP development.
Despite the popularity of CMPs, there still exists some confusion about how to
maintain a multidisciplinary focus while encouraging all disciplines to use CMPs.
Selling the use of CMPs to a diverse and large group of providers is not an easy
task. Obtaining buy-in from the different disciplines requires special tactics
and political correctness. Using multidisciplinary teams for the development,
implementation, and evaluation of CMPs is a move in the right direction. However,
this is not the answer to all concerns. Tahan
(1998) described 14 strategies that can be used for enhancing the multidisciplinary
nature of CMPs and the participation of the different providers in their development.
These strategies are summarized in Box 8.
Interdisciplinary teams need an average of six to eight meetings,
1 hour each, to complete a CMP. The following sections outline an example of how
the work of the team should be planned.
Preparation Meeting The steering committee assigns the team leader and
facilitator based on the specific case type/CMP to be developed. A meeting is
then held between representative(s) from the steering committee and the leader
and facilitator, during which the goals and expectations of the interdisciplinary
team are discussed. During this meeting the following issues are finalized:
Membership of the team,
including physicians
Length of stay of the
CMP
Training and education
of the team members
Date, time, and place
of the team's first meeting
Finalizing the agenda
of the first meeting
Notifying team members
of their participation on the team
Establishing a timeline
for the team's work and a target date for completion of the CMP
Sharing of the available
data (previous administrative, length of stay, and utilization
review reports) related to the CMP type
Interdisciplinary
Team's First Meeting During the first meeting, the interdisciplinary team
leader discusses the team's goals and expectations and the timeline for completion
of the expected work. A list of all team members and their phone numbers is distributed.
If the CMP development form is not already completed and submitted to the steering
committee, it is finalized during this meeting. This meeting is geared toward
educating the team members. The issues discussed include the following:
The process of developing
a CMP
Goals for improvement
Specific discussion regarding
the responsibilities of each member in the development of the CMP
The template of the CMP
as provided by the steering committee
The available data related
to the particular case type and examples of CMPs from other institutions
Assignments for the next
meeting (plan of care related to each discipline)
Finalizing the meeting's
schedule (date, time, location, and frequency)
Second
Meeting During the second meeting, team members conduct a medical
records review and discuss the following:
The preliminary plan
of care prepared by each member of the team as it relates to the discipline
he or she represents
The timeline placement
of the recommended interventions
The assignment for the
next meeting (finalize the plan of care of each discipline)
Third
and Fourth Meetings During the third and fourth meetings the team finalizes
the recommended plan of care, compares the ideal/best practice with the review
of literature available, and makes changes as needed. The team starts to discuss
the expected outcomes of care and does the following:
Finalizes the interventions
and the treatment plan
It is necessary for each
institution to have a steering committee to oversee the development, implementation,
and evaluation of CMPs.
It is more effective
to have a formal process and structure for developing CMPs.
CMPs should be developed
based on the literature, particularly research and evidence-based practice,
expert opinion, and recommendations of professional organizations and societies.
It is important to seek
the input of all healthcare providers involved in the care of a particular
patient when developing a CMP.
The CMP, after it is
piloted and approved, should become the institution's standard of care and
applied by all practitioners.
The interdisciplinary
team charged with developing a particular CMP should be given enough guidance
by the steering committee and provided with appropriate training and education
regarding the process.
CMPs should have the
Milliman & Robertson Guidelines and InterQual criteria built in to ensure
cost-effective and quality outcomes.
InterQual,
Inc:System administrators guide, Marlborough,
Mass, 1998, InterQual.
Janken J, Grubbs J, Haldeman K:
Toward a research-based critical pathway: a case study, OJKSN document no. 1C,
July 1, 1999 (clinical column). Available online at http://www.stti.iupui.edu/library/ojksn/cc_doc1c.pdf.
Katterhagen JG, Patton M: Critical pathways in oncology:
balancing the interests of hospitals and the physician, J
Oncol Manage 2(4):20–26, 1993. Meister S, Rodts B, Gothard J, et al: Home Care Steps protocols:
home care's answer to changes in reimbursement, J Nurs Adm
25(6): 33–42, 1995.
Parker C: Patient pathways as a tool for empowering patients,
Nurs Case Manag 4(2):77–79, 1999.
Schibanoff JM, editor:Health care
management guidelines, New York, 1999, Milliman & Robertson.
St. Anthony Publishing: DRG: working
guide, Alexandria, Va, 1992, St. Anthony.
Tahan H: The multidisciplinary mandate of clinical pathways
enhancement, Nurs Case Manag 3(1):46–52, 1998.
Tahan HA, Cesta TG: Developing case management plans using
a quality improvement model, J Nurs Adm 24(12):49–58,
1995.
Thompson KS, Caddick K, Mathie J, et al: Building a critical
pathway for ventilator dependency, Am J Nurs 91(7):28–31,
1991.
Zander K: Care maps: the core of cost and quality care,
New Definition 6(3):1–3, 1991.
Zander K: Physicians, care maps, and collaboration, New
Definition 7(1):1–4, 1992.
APPENDIX3-1
CASE MANAGEMENT PLANS This appendix presents a template for case management plans.
Case management plans usually delineate the standards of care; identify patients'
actual and potential problems, the goals of treatment, and the necessary patient
care activities; and establish the projected outcomes of care.
Things to Remember About Developing Case Management
Plans
Establish an interdisciplinary
team.
Identify team members
based on the diagnosis or surgical procedure in question. Members should be
chosen based on their clinical experiences, leadership skills, communication
skills, tolerance to hard work, and commitment to the institution and the
project.
Identify a team leader
and a facilitator.
Provide the team with
administrative and clerical support.
Establish a project work
plan (timeline of activities) before the team's first meeting.
Train team members in
the process of developing CMPs.
Team members should prepare
their work in between meetings. Meetings should be held to review the work
and determine the next steps.
Regardless of the format
of the CMP, it should always include the patient care elements as identified
by the organization, the patient problems, projected length of stay and outcomes
of care, a variance tracking form, and patient care activities and interventions.
Create a timeline for
the CMP as indicated by the care setting. For example, minutes to hours in
emergency departments, number of visits in clinics and home care, days in
acute care, weeks in areas of longer length of stay such as neonatal intensive
care area, and months in nursing homes and group homes. The timeline of CMPs
in subacute care and rehabilitation centers can be established based on the
length of stay, goals of treatment, and intensity of activities. For the most
part, it is daily or weekly.
Preestablish the expected
(acceptable) length of stay.
Determine the mechanism
for tracking variances and define the variance categories to be evaluated.
Ensure that the CMP is
the standard of care applied by all healthcare providers, including physicians.
Include patient and family
teaching and discharge planning activities in all CMPs.
Determine whether CMPs
are a permanent part of the medical record.
Maximize documentation
on the CMP. Require all patient care services to use the CMP for documentation.
Develop CMPs based on
the latest recommendations of research and professional societies.
Avoid being rigid in
recommending treatments. For example, use words like “consider” when including
treatments, medications, or interventions that may not be applicable to every
patient, completion may not always be possible within the indicated timeframe,
or progress may be dependent on the patient's condition.
Identify the intermediate
and discharge outcomes of care in each CMP.
Delineate the ICD-9-CM
code or the DRG number of the CMP on the cover page.
Include all disciplines
involved in the care of patients as indicated by the diagnosis or surgical
procedure considered.
Stress the importance
of patient care activities that historically were identified as problem areas
or requiring improvement.
Establish a timeframe
for reviewing and revising the CMP.
TEMPLATE
OF A CASE MANAGEMENT PLAN
___________________________________________________
*Part of this material first appeared in Tahan HA: A ten-step process to
develop case management plans, Nurs Case Manag 1(3):112-121,
1996.
__________________________________________________________