Tackling case management models at the patient/family level

The main dilemma for the boardroom and the frontline case management professionals is they do not warm up to “models.” In fact, models are looked at with skepticism, and if they are being evaluated, models are looked at as warnings about more work to come.

In addition, the broader the model, the more it is lost on the person who is supposed to work in it. The narrower or more specific the model’s description is, the more difficult it is to use, and hence, the more frustrating.

Looking at the patient/family level of care, every patient and family should receive the following services from case management:

1. Support of nationally published patient rights, including the right to be treated with dignity
2. Accurate, factual, and timely communication about the patient’s admission to all members of the treatment team in acute care and the next level of care
3. Empathy for the patient and family story surrounding the admission, regardless of payer, socioeconomic status, or specific circumstances that precipitated the need for care
4. Advocacy for unique, individual needs
5. Coordination of timely, strategic interventions that result in outcomes that are important to the patient and, if possible and legal, the family
6. Assessment within 24 hours of admission to address demographics, risk stratification, and attribution of readmission
7. Procurement of funding and detailed arrangements for a safe, smooth, and sustained transition to the next level of care that will promote recovery, restoration, the highest level of wellness possible, or a comfortable death (i.e., provision of options to meet activities of daily living and instrumental activities of daily living)
8. Immediate access to social work services as needed or requested for skilled support during the course of the hospitalization, for family meetings, and to discuss near future healthcare decisions
9. The help of a case management liaison between the immediate healthcare team and the payer/payer regulations
10. Access to financial planning if needed or requested
11. Information about whom to contact if needed post-discharge until the patient is under the care of the accountable person at the next level of care
12. Knowledge that data collected from the patient and family will be evaluated in detail and included in trended data to improve the clinical outcomes and inpatient experience of others

Editor’s note: For more information, see Case Management Models: Best Practices for Health Systems and ACOs, Second Edition.