The position of nurse case managers can be a rewarding but challenging career, as these managers play a vital role in a patient's care. In A Guide for Nurse Case Managers, author Charlotte Cox provides an insightful guide to this evolving field of medicine. Geared for those working in hospital settings, clinics, and health plan offices, this helpful reference text provides guidelines, tips, and tools for becoming a successful nurse case manager. With more than thirty years of health care experience, Cox provides a detailed overview of this important nursing position that works to usher a patient through the health care system. A Guide for Nurse Case Managers ¿ defines the case manager role; ¿ provides an understanding of the basics of utilization and case management; ¿ gives an overview of Medicare and Medicaid procedures; ¿ discusses the care planning process; ¿ shows how to structure a community resource base. Whether you are a new case manager, a student, or a seasoned nurse needing a refresher about job basics, A Guide for Nurse Case Managers will help to shape your practice, provide valuable tips and reference tools, and help you with proven organizational ideas to succeed in the career.

A Guide for Nurse Case Managers

By Charlotte Cox

iUniverse, Inc.

Copyright © 2010 Charlotte Cox
All right reserved.
ISBN: 978-1-4502-3855-7

Contents

Disclaimer................................................................................viiPreface-Note to the Reader................................................................ixAcknowledgments...........................................................................xiiiChapter 1: The Case Manager Role..........................................................1Definition of Case Management.............................................................1Nurse Case Manager Functions..............................................................2Brief Overview of the Case Manager Utilization of the Nursing Process.....................2Chapter 2: Care Planning Processes........................................................5Care Planning Guidelines..................................................................5Patient Needs Assessment Guide............................................................8Patient Prescription Assessment...........................................................12Chapter 3: Balancing Utilization Management Practice......................................19Precertification Process..................................................................20Insurance Review..........................................................................21Denial Process............................................................................22Length-of-Stay Issues.....................................................................25Hospital Patient Status...................................................................27Chapter 4: Medicare/Medicaid..............................................................31Medicare Basics...........................................................................31Medicaid Basics...........................................................................33Chapter 5: Tapping into Community Resources...............................................35Develop a Community Database..............................................................35Chapter 6: Quick Reference Tools..........................................................41Tool #1: Medicare Information Tool-2010...................................................43Tool #2: Medicaid Information Tool-2010...................................................44Tool #3: Case Management Patient Needs Assessment Guide...................................45Tool #4: Patient Assessment Form..........................................................46Tool #5: Resource List....................................................................48Tool #6: Clinical Review Format...........................................................49Tool #7: Payer Basics.....................................................................51Tool #8: Patient Prescription Assistance Guide............................................53Tool #9: Patient Prescription Assistance Form.............................................55Tool #10: Consent for Case Management Services............................................57Chapter 7: Conclusion-Ready, Set, Go......................................................59About the Author..........................................................................65Definitions and Terms Related to Utilization and Case Management..........................67References................................................................................73

Chapter One

The Case Manager Role

Definition of Case Management

Let's begin by defining case management. The Commission for Case Manager Certification (CCM) states, "Case Management is a collaborative process that accesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes."

You're hired as nurse case manager. As you begin this new career in nursing, questions surface about the role. Beginning with the very first day of orientation, terms, such as utilization, discharge planning, and insurance contracts, heighten your interest. This verbiage is only the start of a new language of nursing. You also hear discussions regarding length-of-stay issues, variance tracking reports, and insurance authorizations, as the list continues.

It isn't long before you figure out that case management is unlike any other nursing field you've experienced. Wow! This is such a new avenue of nursing for you and many others.

Nurse Case Manager Functions

The nurse case manager is the one person who guides the patient through the health system. Service areas include hospital case management, worker's compensation, health plans, disease management, outpatient care, military programs, and agencies providing services to the homebound patient. Many avenues exist, allowing the case manager to assess and plan for life-care changes for any age group.

Depending on the facility program, social workers and case managers may perform similar duties in providing case management. The nurse case managers educate the patient with vital information regarding their disease process and expected outcomes, while coordinating services as identified in patient/ family interviewing.

Brief Overview of the Case Manager Utilization of the Nursing Process

A thorough assessment reveals actual or potential patient needs for which the nurse case manager can then begin planning and coordinating services as applicable. Handy assessment tools used during the interviewing process will help the case manager organize caseloads. Once all parties agree on the needs identified and the plan outlined to meet the needs, the case manager will then coordinate and implement the individualized case plan.

This nursing process requires excellent communication across the continuum of care among health-care providers. Don't forget to include the immediate family members and significant others, who play an important role in helping our patients meet their care needs. As a patient advocate, the nurse case manager seeks quality, cost-effective resources in order to meet the identified care needs.

Just remember to follow the Health Insurance Portability and Accountability Act (HIPAA) guidelines during initial interviews in discussing care needs and discharge/home care plans. This act, which was passed in 1996, allows the federal government to regulate certain aspects of the health insurance industry. It also addresses the rights of employees, patient privacy/confidentiality standards, coding/transactions, and oversight of insured and noninsured clients.

Once the case plan is implemented, the nurse case manager follows up to ensure the patient care needs are indeed met. This process includes coordinating insurance updates and selected agency/facility input. An evaluation process is vital to ensure the intended outcome is successful.

If the plan fails or is inadequate to fully meet the identified patient needs, the nurse case manager starts over. The process begins with reassessment followed by planning, implementation, and evaluation. Don't fret; many patient care plans change in midstream or as needs change in cases involving long-term medical disease processes. View this curvature as a challenge to sharpen your skills within the field of case management.

Patients and families are grateful that the nurse case manager is coordinating the hospital discharge plan or...