Third Party Payer Managed Care 

          Third party payer managed care refers to “any health care delivery system in which a party other than the health care giver or the patient influences the type of health care delivered” (Cohen & Cesta, 1997, p. 117).  Third party payer managed care is a business venture by managed care organizations that strives to provide efficient, cost-effective, quality health care (Catalano, 1997).  The goal of third party payer managed care is to deliver the maximum level of patient care at a rock-bottom price.  In other words, the intention of third party payer managed care is to get the most out of the managed health care subscriber’s dollar.

          In third party payer managed care, the managed care organization takes the risk for providing the patient’s health care (Cohen & Cesta, 1997).  Taking the risk for providing the patient’s health care allows the managed care organization to dictate what it considers suitable health care for the patient (Cohen & Cesta, 1997).  Third party payer managed care frequently involves an outlined delivery system of health care providers with some form of contractual agreement with a managed care organization.  Contracted managed care providers may accept capitated payment for delivering all medically necessary care to subscribers who are covered by the managed care organization or they may be compensated on a discounted fee-for-service basis or a combination of both of these payment methods (Block, 1997).  Third party payer managed care is a large umbrella under which sit a variety of managed care plans.

          Block (1997) notes, “The Health Insurance Association of America (HIAA) defines managed care plans as plans that integrate the financing and delivery of appropriate health services to covered individuals”.  According to Block (1997), HIAA deems the fundamental components of managed care plans to be: 

1.  “Arrangements with selected providers to furnish a comprehensive set of health care services to members; 

2.  Explicit standards for the selection of health care providers; 

3.  Formal programs for ongoing quality assurance and utilization review; 

4.  Significant financial incentives for members to use providers and procedures associated with the plan; 

5.  Incentives for plans and/or providers to limit unnecessary procedures and procedures of questionable benefit”

Under third party managed care, patient health care is provided via these managed care plans.  The four main managed care plan categories are Health Maintenance Organizations (HMOs), Independent Practice Associations (IPAs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans.

          A Health Maintenance Organization provides a prepaid health care plan that delivers comprehensive health care to a group of subscribers for a monthly fee (Block, 1997).  This prepaid health care plan also includes a contracted set of health care benefits.  The monthly fee paid to the plan covers all of the needed health care for the subscribers as long as the care is within the contracted set of health care benefits.  The Health Maintenance Organization accepts financial risk for all of its subscribers’ health care needs (Block, 1997).  In an HMO, a primary care physician is frequently charged with authorizing any specialty services provided to a subscriber.  This means a subscriber cannot be seen by a specialist or have procedures performed without a referral from the primary care physician.  Generally, subscribers may see only physicians employed by or under contract with the HMO.  When subscribers use a physician employed by or contracted with the HMO, health care expenses are usually covered in full (Block, 1997).  Some plans may have a flat amount co-payment for plan physician office visits.  If subscribers choose to seek health care outside of the HMO system, that health care may not be paid for by the plan.  “The term Health Maintenance Organization was coined by Dr. Paul Elwood in the hope that by creating a prepaid payment system which would cover all needed care, the HMO would have the incentive to keep its enrollees healthy by promoting good health and preventing disease, since the more care the HMO is required to provide, the higher the cost of providing the care” (Block, 1997).

          Block (1997) states five HMO models exist.  These five HMO models contrast with regard to the organization that provides the health care services and the exclusive relationship between the monetary negotiator and the actual health care providers (Block, 1997).  The five HMO models are as follows: 

          Independent Practice Associations (IPAs) are a variation of the traditional HMO. IPAs are generally organized by physicians or groups of physicians and health care institutions for the purpose of contracting with a managed care organization in order to provide health care for its members on a capitated basis. IPA subscribers are charged for health care service each time that the care is provided. This is different from HMO plans, “…in which members pay premiums and are not charged for each service individually” (Catalano, 1996).  Like HMOs, IPAs generally do not reimburse for health care services performed by non-member providers. To keep costs in check, IPAs must adhere to guidelines that specify the amount of health care services that can be rendered by a health care provider (Catalano, 1996).

          Preferred Provider Organizations (PPOs) are limited groups of physicians and health care facilities that are contracted by employers, insurance companies, or other health care plans to provide health care services to subscribers at discounted rates (Catalano, 1996).  The physicians and health care facilities enter these PPO health care contracts in the hopes of receiving an increased number of patients. Within PPO plans, physicians are reimbursed on a reduced fee-for-service schedule and subscribers are charged a co-payment at the time health care is provided (Catalano, 1996).  “The copayment requirement is thought to decrease client use and thus reduce costs” (Catalano, 1996).  With PPOs, the financial risk does not lie with the provider group but is instead the responsibility of the employer, insurance company, or health care plan that contracted with the provider group.  The major difference between HMOs and PPOs is that PPOs allow subscribers to be treated by a non-PPO members subject to a higher out-of-pocket expense (Cohen & Cesta, 1997).  This is a strong financial incentive for subscribers to seek medical treatment from health care providers within the PPO system.

          Point of Service (POS) plans are plans that use financial incentives to encourage subscribers to receive health care from contracted physicians.  In POS plans primary care physicians are paid monthly capitated fees for each subscriber cared for (Cohen & Cesta, 1997).  POS plans, like PPOs, allow subscribers to see physicians outside of the plan for an increased co-payment and/or deductible amount.  A difference between a PPO and a POS plan is that a POS plan has primary care physicians who must pre-authorize health care procedures and referrals to health care specialists (Cohen & Cesta, 1997; Block, 1997).  

Unit-Based Managed Care 

          Unit-based managed care is a patient-focused technique for managing or directing a patient’s care through a hospital stay.  It is a unit-based patient care delivery system in which specific patient outcomes are intended to be met within a set amount of time.  A primary nurse is held responsible for ensuring patient outcomes are met within the designated time frame.  One of the premises of unit-based managed care is that it approaches patient care holistically.  Unit-based managed care is a collaboration between all health care disciplines to meet the same patient-centered goals.  In unit-based managed care critical pathways are used to guide patient care.  The goals of unit-based managed care include: 

·        Assurance that patients receive timely access to the suitable level of health care services. 

·        Appropriate utilization of health care resources. 

·        Collaboration among all health care disciplines to facilitate coordinated achievement of set patient outcomes. 

·        Continuity of patient care. 

·        Coordination of timely patient discharge. 

·        Support of the nursing staff’s job satisfaction and professional growth.(Smith et al, 1994)

Utilization Management 

          Utilization management is a hospital-based program that appraises quality and cost-effectiveness of delivered health care services based upon patient outcomes that have been developed with input from all patient care disciplines in collaboration with the medical staff.  Utilization management is a system designed to monitor the health care services the patient is receiving for appropriateness and medical necessity (Skinner, 1997).  “The objective is not only utilization review for reimbursement, but also to truly manage what is best for the patient” (Homa-Lowry, 1992). 

          Hospital-based utilization management in one form or another is mandated for quality health care delivery by not only federal (Health Care Financing Administration - HCFA) and state (Title 22 - California) regulatory agencies that inspect, certify, and/or license health care facilities but by private accreditation surveyors (Joint Commission on Accreditation of Healthcare Organizations - JCAHO) as well.  To guarantee quality health care conveyance and cost-containment, utilization management is also required by third party payers as part of their contractual agreements with health care facilities.  To ensure the provision of quality health care services, professional peer review organizations which review physicians’ practices and the physician and nursing professional codes of ethics also oblige some form of utilization management/review.

          Utilization management concepts were introduced because of the need to manage high-cost inpatient admissions and expensive health care procedures.  Utilization management’s focus is on determining whether the assigned level of health care is appropriate for what is going on with the patient.  Utilization management assists in identifying patients who are ready for transfer to a lower level of care and verifies which patients have progressed to discharge.  (See Table 3-1.)  Utilization management looks at severity of illness (SI) and intensity of service (IS).  Severity of illness (SI) refers to the symptoms and abnormal clinical findings manifested by the patient, and intensity of service (IS) is the type and frequency of medical treatment that can be expected to be rendered to a hospitalized patient with a particular diagnosis and/or symptoms.  There are three components to the utilization management process.  These components are the prospective or admission review, the concurrent or continued stay review, and the retrospective review.

          The prospective or admission review is executed prior to the actual delivery of a health care service and/or medical treatment to verify medical necessity of the care.  The concurrent or continued stay review is conducted while the patient is receiving health care services and/or medical treatments.  This component of utilization management verifies that the patient’s continued stay or ongoing treatment is medically necessary, appropriate for the patient’s health care needs, and is carried out according to set time frames.  If the patient is on a clinical/critical pathway, the concurrent or continued stay review will look carefully at that pathway for crucial patient outcome and variance information.  Other patient care information that a concurrent or continued stay review analyzes is: 

·        The patient’s clinical diagnosis (reason for admission). 

·        Present and recent (within the last 24 hours) data including but not limited to:

         *Laboratory values.

         *Signs and symptoms elicited by the patient.

         *Diagnostic studies including radiology reports.

         *Nutritional supplements: -TPN.

         *Vital signs including neurovascular assessments and telemetry.  

           -24-hour trends, increases/decreases, or any other abnormalities.

           -Frequency of monitoring (every 2 hours or greater).

         *Intravenous fluids:

           -Rate.

           -Intravenous medications (frequency and number).

           -Pain medications (the need for intravenous versus oral and frequency).

           -Blood and/or blood products transfusions.

         *Intake and output (I & O):

           -Gross deviations from fluid balance. 

·        Planned treatments and procedures:

         *Medical procedures.

         *Surgical procedures including bronchoscopies, cystoscopies, endoscopies etc.

         *Wound care (degree, size, and depth).

         *Respiratory treatments (at least three times per day):

           -Oxygen.

         *Therapies (frequency, stability, progress)

           -Physical therapy.

           -Occupational therapy.

           -Speech therapy. 

·        Consultations:

         *Timeliness of response to request for consultation.

         *Recommendations for treatment. 

·        Continued care issues:

         *Durable medical equipment needs.

         *Skilled Nursing Facility (SNF).

         *Rehabilitation unit.

         *Subacute unit/facility.

         *Board and care home.

         *Home Health Care. 

When doing a concurrent or continued stay review, a good question to ask is:  “Why is the patient in the hospital, and what medical treatments is the patient receiving that can only be delivered in the acute care setting by acute care practitioners?”  The retrospective review is carried out after the patient has been discharged from the hospital or after the health care services have been provided.  The retrospective review examines practice standards that may have resulted in over or under utilization of health care resources.  A retrospective review may also be conducted by third party payers, for reimbursement purposes, to verify the medical necessity of the treatment the patient received. 

Case Management 

          Case management in one form or another can be found across all health care disciplines.  From its social beginnings to its present day health care applications, case management has been proven to be a superior method for coordinating and managing care in a variety of settings including community and mental health and long-term care (Bayard et al, 1997).  Case management is fast becoming the preferable system for coordinating care in the acute care setting.  “The limitations of our health care system to recognize the need to integrate services has served as a catalyst for the development of (contemporary) Case Management” (McMurry, 1997).  Cohen and Cesta (1994) note, “Contemporary approaches to case management reflect the interests and needs of a highly sophisticated, service-oriented, consumer population”. 

          Case management is generally identified with both coordination of health care services and cost containment.  McMurray (1997) writes, “The Case Management Society of America’s (CMSA) Standard of Practice defines case management as a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s

health needs through communication and available resources to promote quality cost-effective outcomes” .  Nugent (1992) notes, “The American Nurses’ Association (1988) defines case management as a health care delivery process with the goals of providing quality health care, decreasing fragmentation, enhancing the client’s quality of life, and containing costs” (p.106).  Case management could also be defined as all health care disciplines working in collaboration to ensure that the patient receives opportune and appropriate quality health care with attention given to cost-effectiveness and positive outcomes.  Although the definitions of case management differ somewhat, the underlying theme is the same – the timely coordinated delivery of high-quality, necessary health care at a fair price.  Other terms for case management include care management, care coordination, and/or health care service coordination.

          Case management incorporates the basic elements of managed care, and the working components of case management are analogous to the steps of the nursing process.  Case management “…is a response to the complex, costly, catastrophic needs of the chronically ill, the disabled, and the frail elderly” (McMurray, 1997).  Case management organizes patients by specific case types, such as cardiac or orthopedic and strives to accomplish a connection between quality patient care and the expenses involved in providing the care.  Case management focuses on a patient’s entire episode of illness from admission to discharge to community-based interventions post discharge. 

          Although the main focus of case management is on the monitoring of health care services and the timely coordination of health care resources to productively progress a patient to discharge or the appropriate level of care, the importance of prevention and wellness strategies as well as redesigning how health care is to be delivered are also being emphasized (Nugent, 1992; Cohen & Cesta, 1994).  Case management is devised to accomplish a pre-decided set of patient outcomes within a fixed time frame (Altizer, 1997).  According to Johnson and Proffitt (1995), “most typically, case management is implemented to:  (a) achieve a set of predetermined outcomes; (b) promote coordination and continuity of care through collaborative or multidisciplinary practice; (c) ensure proper resource utilization; (d) support achievement of LOS (Lengths of Stay) targets; and (e) promote professional development”.  Case management affords a plan for standardization of patient care practices.  The patient, the patient’s support person(s), the physician(s), the case manager, and all the other health care disciplines caring for the patient are informed of the patient care goals and needed interventions at the outset of treatment.  Standardization of patient care practices helps to ensure appropriate, timely patient care. 

          Commonly, case management is coordinated by appointed patient case managers who possesses advanced skills in planning, coordinating, and evaluating patient care.  These designated case managers, in collaboration with the physician(s) and all other health care disciplines caring for the patient, plan, coordinate, and evaluate patient care for a defined population of patients utilizing critical pathways as directives.  Generally, direct patient care is implemented by the patient care team which is comprised of both licensed and unlicensed staff.  Critical pathways are standardized plans of care which designate expected patient outcomes that must be accomplished within a given time frame (Catalano, 1996).  However, when critical pathways are not available, case managers have implemented goal-directed case management plans developed in conjunction with the health care disciplines caring for the patient, the patient, and the patient’s support person(s).

          Roberts-DeGennaro (1993) explains there are five fundamental steps to the process of planning and establishing health care goals.  The first step in the process is for the case manager, any health care disciplines caring for the patient, the patient, and the patient’s support person(s) to discuss the patient’s health care needs and life situation to ascertain what health care goals need to be set.  The second step is for the group to cooperatively formulate health care goals that can be met within the allowed length of stay.  In the third step, the parties review the patient’s strengths and identify how these strengths can help with goal achievement.  The fourth step involves listing the actions which need to be carried out for each goal to be met.  The fifth and final step involves the case manager’s identifying who will do each specific action and the time frame for the completion of the individual actions.  Case management organizes patient care using a team approach.  It makes the whole patient care picture clear to all members of the health care team.  According to Cohen and Cesta (1994), “Case management works because it links previously disconnected disciplines and departments within the hospital”.  For case management to be successful, the patient needs to be fully involved in the care, and the case manager and all health care disciplines involved in caring for the patient must communicate, participate in the plan of care, and anticipate the same patient outcomes, regardless of what case management tools are used to guide patient care.  Case management allows patients and their support person(s) to make informed determinations about health care based on the patient’s needs, capabilities, resources and personal likes and dislikes.

          Although there are a variety of case management models currently being utilized, coordination of care is the rudimentary element of all models of case management.  Cohen and Cesta (1994) note “case management delivery models must be patient-focused; they must be designed to provide quality care that is satisfying to patients and families” while at the same time maintaining appropriate health care resource utilization.  Many hospitals have individualized a case management model to fit their particular needs.  Case management has become a delivery of care model which has assisted hospitals in meeting the conditions of a redesigned health care delivery system while continuing to provide the quality care demanded by the patients they serve (Smith & Wolf, 1997).  Because there is a need to have an experienced clinician at the bedside to facilitate appropriate health care decision making for the complex patient population now being cared for on general medical/surgical units, the most commonly seen adaptation of case management to the hospital setting utilizes registered nurses as case managers (Cohen & Cesta, 1997; Conger, 1998). 

Bedside Case Management 

     Bedside case management encompasses the essential components and techniques of case management with one distinct difference – the case manager is the nurse at the bedside participating in direct patient care. This model of case management works because the nurse at the bedside has a great deal of patient care contact which provides the most accurate and current information on the patient’s condition and responses to treatment, and because the nurse at the bedside interacts daily with all other health care disciplines involved in caring for the patient (Marr & Reid, 1992).  The nurse at the bedside is in a good position to promote collaboration among all hospital departments in order to ensure the delivery of skilled, quality patient care that is in compliance with all of the regulatory agencies’ and third party payers’ requirements.  In bedside case management, general case management principles work in symphony with the extensive skills and comprehensive knowledge base the nurse brings to the bedside to maximize the benefits the patient receives.  Within the scope of bedside case management, the nurse case manager “assumes a planning and evaluative role over many different departments with which the patient will interact and takes on the role of a problem solver and a fixer of systems that stand in the way of effective delivery of care” (Vestal, 1995, p. 40).  Karen Zander, RN, MS, CS (1988), credited with the development of the first nursing case management model, lists the following four components of nursing case management:  “(1) achievement of clinical and financial outcomes within the DRG-allotted time frames; (2) the care giver as case manager; (3) episode-based RN-MD group practices that transcend units; (4) active participation by patients and their families in goal setting and evaluation”.

          All professional nurses are, in reality, already somewhat versed in case management application.  Using the nursing process, nurses have been coordinating patient care since the beginning of nursing.  The nursing process has fostered in the nurse a problem-solver approach to patient care that integrates well into the case manager role.  “Given appropriate tools (critical pathways) and support (a case manager resource person), professional nurses can expand their individual practice to a more comprehensive, holistic, case management level” (Rawsky, 1996) and having a more holistic view of patient care enables the nurse case manager to better anticipate the patient’s health care and discharge planning needs.  “This role enables the nurse to achieve the full scope of professional practice, think critically, solve problems effectively, and incorporate clinical, managerial, and financial/business skills into the decision-making process” (Tahan, 1993).

         Bedside case management expects the nurse case manager to perform all aspects of professional nursing practice at a higher level.  The nurse case manager needs to be more familiar with and adaptable in the patient care provided, and also needs to become well-acquainted with the financial aspects of patient care.  Bedside “case management addresses the current demand for nurses to do more with less” (Milne & Pelletier, 1994).  Like case management, the intent of bedside case management is to increase the quality and cost-effectiveness of patient care.  Zander (1988) writes of nursing case management, “Nursing Case Management, which establishes the staff nurse as case manager, is a technology that resolves the cost/ quality puzzle through a clear understanding and restructuring of the clinical production processes at the provider-consumer level… It builds on the concept of managed care and the accountability practiced in primary nursing” (p.503).  Nursing case management varies from primary nursing in that the nurse case manager’s main focus is on planning, coordinating, and evaluating patient care with other patient care team members dealing more with patient assessment and care interventions (Marquis & Huston, 1992).  Clinical nurse specialists at Crawford Long Hospital of Emory University identified the following six nursing case management goals: 

          Bedside case management is based on the assumption that the nurse at the bedside, given relevant information and thorough preparation, is the prime candidate to address how any employed cost-containment approaches affect the quality of patient outcomes.  The nurse at the bedside is in the best position to ascertain which cost containment approaches best serve each patient’s individual needs.  The literature shows that some of the best patient outcomes and cost containment occurs in a bedside case management model of care (Bair et al, 1989; Tahan, 1993; Smith et al, 1994).  The nurse case manager is held accountable for both the clinical and economic outcomes associated with patient care.  In addition, to ensure that progress occurs within the time allotted by DRGs or third party payers, the nurse case manager is responsible for closely monitoring the patient’s advancement toward discharge or a more appropriate level of care.  “Financial accountability and utilization strategies at the bedside involve educating the nurse about coding issues such as DRG assignment, complications and co-morbidities, PPS [Prospective Payment System], length of stay (LOS), case management plans by which to evaluate the patient’s progress, and a working knowledge of community services available to the patient upon discharge” (Bair et al, 1989). 

          In bedside case management, the nurse case manager coordinates all aspects of patient care utilizing critical pathways or some other form of case management plan as a guide, provides patient education, and participates in some hands-on care.  When a critical pathway is used to direct patient care, the nurse case manager “…ensures the milestones on the critical pathway are met” (Vestal, 1995) within the designated time frames.  The nurse case manager assesses for and identifies patient health care and discharge needs and, in collaboration with the patient, the patient’s support person(s), the physician(s), and the other health care disciplines caring for the patient, formulates an individualized case management plan to meet those needs.  “Integrating the interventions of all disciplines into the nursing care plan promotes coordinated care and negates the potential for fragmentation of care” (Nugent, 1992).

          The nurse case manager works jointly with physicians, other health care disciplines, and third party payers to render cost-effective, quality patient care in a non-hierarchical form of group practice.  Each member of the group is equally important to the achievement of set patient outcomes.  “A successful collaborative practice is dependent upon interdependent and cooperative decision making as well as the sharing of knowledge, goals, confidence, and mutual trust” (Nugent, 1992).  Communication among group members is imperative for the successful delivery of quality patient care.  Patient rounds in which all health care disciplines involved in caring for the patient, the patient, and the patient’s support person(s) participate in information sharing is a vital component within the communication process.  Patient care continues on a smoother course because of the contingency planning that occurs during patient rounds, and also because all ideas and viewpoints that are shared during patient rounds are merged into a harmonized and thorough case management plan (McHugh et al, 1996).  The nurse case manager acts in a patient advocacy role ensuring quality patient care while at the same time addressing cost containment approaches that promote sound utilization of resources and patient discharge within a defined length of stay (Bair et al, 1989).  By practicing at the bedside, the nurse case manager can more easily identify issues that need improvement and cost-containment strategies that affect the quality of patient outcomes.  The identification of improvement issues will lead to collaborative solutions that increase the quality of overall patient care and may lead to the development of patient care protocols. 

          Within the shared group practice framework, bedside case management involves a patient care team approach to cost-effective, outcome-oriented, quality patient care.  The structure of the patient care team is similar to the nursing teams of the 1960s and 1970s with one significant difference – the 1990s registered nurse has more management responsibilities.  The team generally consists of staff (RNs, LV(P)Ns, nursing assistants, and/or unlicensed assistive personnel) who perform direct patient care at various skill levels.  This allows for the full use of knowledge, skills, and abilities of all team members.  The registered nurse performs the nurse case manager role of supervising the patient care team and planning, coordinating, and evaluating patient care for a select group of patients.  The patient care team assists the nurse case manager in implementing the planned care for the patient group.  To judiciously delegate patient care tasks, the nurse case manager supervising the team must be aware of the competency of each team member providing care to the assigned group of patients.  Every member of the patient care team has an essential role to play in successfully progressing each patient in their group from admission to discharge in a timely, proficient way.  If any team member fails to appropriately intercede at the right time, each patient’s individual progress could be thwarted possibly resulting in an unnecessary increase in resource utilization and/or length of stay.  Patient care is centered on the needs of the patients, not the needs of the patient care team; therefore, the input of the patients and the patients’ support person(s), as health care consumers, is critical to the success of delivering quality care (Cohen & Cesta, 1994; Vestal, 1995).  Based on the patient’s clinical picture and input from the patient care team, patient, and patient’s support person(s), the nurse case manager has the authority to make decisions, that may potentially affect patient and financial outcomes.

          Although the nurse case manager has primary accountability for patient outcomes, the entire patient care team and the patient must be involved in the case management process.  Excellent communication between the case manager, the other members of the patient care team, and the patient is an integral part of the case management process.  Change of shift report is an important link in the communication chain and ideally will include not only the off-going and on-coming members of the patient care team but the patient and the patient’s support person(s) as well.  The intent of the change of shift report is to tune the team that will be assuming patient care into the purpose for the next 12 hours of hospitalization in the context of each patient’s length of stay and anticipated outcomes (Zander, 1988).  To facilitate cost-effective, quality care within a bedside case management approach to patient care, it is important to include the following information in the change of shift report:

·        The patient name, age, and gender. 

·        The patient’s physician(s). 

·        The patient’s diagnosis/reason for hospitalization. 

·        The patient’s actual day of stay number and authorized length of stay.  i.e. “This is day 2 of an authorized 4 day stay.” 

·        A brief overview of the patient’s medical history:

          -Any complications.

          -Any secondary diagnoses. 

·        A brief overview of the patient’s social history:

          -Marital status.

          -Living arrangements.

          -Support system/ family dynamics.

          -Willingness and ability of support person(s) to be involved in the post-hospital care of the patient. 

·        An evaluation of the patient’s progress toward discharge/case management plan goals:

          -Critical pathway movement/outstanding case management goals yet to be met.

          -Variances – what are they and why?

          -Delays in service – type and why?

          -Interventions taken to resolve any variances/delays and their effectiveness.

          -Functional assessment information.

          -Physical assessment deviations.

          -Any abnormals.

          -Discharge planning and continuing care needs.

          -Reimbursement issues or questions. 

·        Any important events anticipated for the oncoming and following shifts:

          -Pathway milestones that will occur/case management plan goals to be  met.

          -Tests, procedures, treatments that need to be done.

          -Scheduled therapies.

          -Patient care issues.  i.e. patient preferences.

          -Patient education that needs to be started, reinforced, or completed. 

·        Any current or pending physician consultations and any follow-up that needs to be completed. 

·        Any referrals that were made or need to be made and any follow-up that needs to be done:

          -Social services.

          -Nutrition services.

          -Pharmacy services.

          -Wound care team.

          -Home health or community services. 

          Another valuable communication tool used in the bedside case management approach to patient care is the intra-shift report which generally takes place at or around mid-shift.  During intra-shift report, all members of the patient care team meet to discuss patient progress for the shift with regard to the key elements contained in the change of shift report.  The main purpose of the intra-shift report is to provide a standard means of communication for keeping the nurse case manager abreast of any developments concerning patient progress and the patient care the individual team members are providing.  This ensures early variance identification and timely problem solving so that each patient’s discharge planning is kept on track.  The information exchanged in the intra-shift report discloses the total patient care picture to the nurse case manager.  Intra-shift report is also a time for the nurse case manager to assist the other members of the patient care team with formulation of action plans relative to the performance of their own individual aspects of patient care.  In addition, intra-shift report provides time for all patient care team members to participate in quality improvement activities and discharge planning.
 

Summary 

          Case management and bedside case management are patient care delivery approaches to managed care.  Both case management and bedside case management embody the general principles of managed care, one of which is the need for utilization management.  The main difference between case management and bedside case management is:  in bedside case management the case manager is the nurse at the bedside who, along with facilitating patient care across all the health care disciplines ensuring all criteria are met, actively participates in direct patient care.
 

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