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Simple Strategies for Effective Home Care Case Management
OBJECTIVE: Upon completion of the in-service, the participant will
be able to:
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Identify, define and develop a case management system to meet
individual patient needs.
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Understand the importance of completing an accurate comprehensive
patient assessment in a standardized manner throughout the
agency's entire multi-disciplinary team.
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Realize the importance of delivering goal driven care for the
homecare patient in order to increase patient outcomes.
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Acknowledge that Communication (to other para and professional
staff, agency management, physician, patient and caregiver/family)
is of utmost importance while providing care to patients; and
understand that all communication must be documented.
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Understand that it is the responsibility of the case manager to
not only coordinate the care and acknowledge problems, but to
follow up on all patient problems.
Introduction
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Effective home care practice is dependent upon the clinician
understanding the system of case-management.
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The primary goal of the home care clinician is to promote healthy
behaviors by planning a course of interventions and developing a
plan to achieve the goal.
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The case manager takes this a step further by coordinating the
patient care with the other nursing staff and healthcare
professionals to ensure a collaborative team approach.
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Unlike Case Managers in other settings, The Homecare Case Manager
focuses on only an episode of care and short term goals.
Steps to Case Management
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Case Management begins with the referral.
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Develop a professional relationship with the patient and family.
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Perform a comprehensive assessment of the patient.
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Establish goals for discharge.
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Identify other disciplines or resources to assist the
patient/caregiver in achieving the goals.
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Communicate to other resources/disciplines assessment findings and
the reason of the referral.
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Break the plan into smaller pieces for the patient.
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Evaluate how the plan is working.
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When discharging the patient, be sure that the assessment is done
in a thorough and objective manner, using the same approaches of
other staff...
The
results of your patient's outcomes and of your agency's public
reporting of its outcome measurements (OBQI) depend on this.
If
the patient has achieved the goals, celebrate the success with the
patient/caregiver and/ or family.
Look at the BIG PICTURE
You
are caring for the patient, not the wound You are coordinating care
and collaborating with multi-disciplines of healthcare
professionals, not acting alone You are working with a patient in
his home environment, with his family or caregivers interacting in a
dynamic fashion Be ACTIVE, not passive You and the other field staff
are identifying issues and concerns relating to your patient's
well-being. Address every one of these issues! You must be
responsible to follow through with problem- solving for your
patient...they are depending on you! Assure that ALL STAFF are also
following up on these issues on every visit and communicating to
you.
COMMUNICATE, COMMUNICATE, COMMUNICATE...
To
the physician, other RN's and LPN's, the Therapists, the Social
Worker, the Home Health Aide, to the patient, to the family and
caregivers
DOCUMENT, DOCUMENT, DOCUMENT...ALL OF THE ABOVE!
You
will feel the reward of knowing that you and your team were
responsible for providing the very best care for your patient!
This is a brief outline of our popular Case Management Seminar. We,
at 5 Star Consultants, feel that Case Management is the key to
successful homecare. By enhancing case management in your agency,
you will be more prepared at all times for regulatory surveys, you
will increase your patient outcomes and your productivity,
particularly of clinical management staff.
However, homecare case management continues to be an area of
challenge. We want to help you overcome this challenge and turn it
into an asset that your agency can use to set you apart from others!
For a customized presentation to your management and/or field staff,
contact 5 Star Consultants today. This session can be by
teleconference or in person!
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