Part Five: Basics of Case Management, Five-Part Series-2024 Basics of Case Mgt Series Part 5 Presentation

2024 Basics of Case Mgt Series Part 5 Presentation

Pdf Summary

The document "Acute Care Case Management: Roles, Functions and Models" by Toni G. Cesta provides an in-depth analysis of case management roles within healthcare settings, specifically focusing on acute care. It delineates the fundamental roles and functions that case managers undertake, varying in application across different environments.<br /><br />Key roles in contemporary case management include patient flow, utilization and resource management, denial management, avoidable delay management, discharge and transitional planning, quality management, and psychosocial assessments. Each role has specific functions essential to their effective execution, such as coordinating patient care, reviewing services for medical necessity, managing third-party payer reimbursements, and planning patient discharges.<br /><br />The text discusses various models of case management, particularly the Integrated and Collaborative models. In the Integrated Model, a single case manager handles all roles and functions, merging previously separate responsibilities and streamlining communication with third party payers. In contrast, the Collaborative Model separates the clinical and business aspects of case management into distinct roles, enabling specialists to focus on specific tasks and collaborate with social workers for psychosocial interventions.<br /><br />The document stresses the importance of consistent goals across these roles: optimizing patient care, preventing delays, ensuring appropriate utilization of resources, and facilitating smooth transitions through care continuums. Effective case management also requires robust staffing, balanced workloads, skilled personnel, and strong leadership, all crucial for achieving desired outcomes and ensuring patient safety and satisfaction.<br /><br />Additionally, the integration of social determinants of health (SDOH) through tools approved by CMS, such as the AHC and PRAPARE, helps address challenges that affect patient care beyond clinical settings. This comprehensive approach aims to improve healthcare delivery by identifying and mitigating barriers related to social and psychological circumstances.

Keywords

acute care

case management

patient flow

resource management

discharge planning

Integrated Model

Collaborative Model

social determinants of health

psychosocial assessments

healthcare delivery