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Limited success has been achieved in identifying high-risk pregnant women via prenatal risk identification tools. The purposes of this study were to examine a risk assessment and nursing telephonic case management protocol used to identify high-risk mothers and infants, and to evaluate the costs and benefits of the protocol. This study involved a retrospective review of insurance data held by a large managed care organization (MCO). Analyzed data included information about current and past medical problems, and current lifestyle risk factors. Data analysis included frequencies, chi2, t tests, and logistic regression analysis. Pregnant MCO members experienced fewer high-risk conditions versus nonmembers. The overall pregnancy cost for a member was 1,818 dollars versus 4,587 dollars for a nonmember. Members experienced 2.5 times fewer babies hospitalized in the NICU, and significantly fewer mothers with high-risk conditions. The MCO program reduces costs and promotes better maternal and infant outcomes.

The Health Insurance Portability and Accountability Act (HIPAA) privacy deadline has passed. Now it is essential to comply with the regulations. The stakes are high; therefore, a HIPAA Privacy Compliance Program must be part of an organization's quality initiatives. This article provides guidelines for the challenges of continual program improvement, successful cultural change, and effective monitoring of the existing program. Healthcare organizations will attain compliance goals through internal audits on the processes, policies, and training efforts of their HIPAA program.

Much of the health news over the last few months has centered on problems elderly patients encounter in obtaining and effectively using the prescription drug discount cards that became available on June 1 under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This article focuses on the next prescription drug newsmaker, Medicare Part D, that will supercede the discount cards on January 1, 2006. There are many complex issues that case managers must evaluate when assisting beneficiaries with queries about "what to do." This article attempts to clarify the "incomprehensible" twists and turns of these issues and provides access to a "Medicare Drug Prescription Benefit Calculator" that may assist the beneficiary and case manager in decision making. Case managers need to understand that there are many opposing viewpoints on this benefit, and it promises to become the subject of a major national debate. For this reason, substantial changes may occur prior to the launch of Part D. If you think discount drug cards are confusing, "you ain't seen nothin' yet!"

Patient safety is an important concern of many healthcare stakeholders, including patients, providers, employers, health plans, and insurers. In 2003, URAC conducted a qualitative study to examine the role of utilization management programs as part of a systemic approach to promoting patient safety. Many of URAC's findings are applicable to case management as well. URAC found that most medical management companies address patient safety indirectly, as part of a global quality management program. Even so, the study identified a number of strengths that could be deployed by medical management organizations to more systematically promote patient safety. For example, case management organizations use decision support tools to assist frontline practitioners in conducting assessments and tracking interventions. Such systems could be programmed to flag safety concerns and guide interventions. The study also found that commonly used case management assessment protocols could be adapted to routinely assess for high priority safety concerns. URAC concluded that each stage of the medical management process offers opportunities for data collection and clinical interface to promote patient safety. Case managers have key positions interfacing between patients, providers, and the healthcare system. Development of safety indicators and training of staff are key elements needed to effectuate a safety program in medical management. Case management leaders in each organization and at the national level should make patient safety a priority, and define the processes for implementing safety systems wherever case management is practiced.

Discharge planning is a legally mandated function for hospitals and is one of the "basic" hospital roles as outlined in Medicare's Conditions of Participation. This article will define discharge planning; describe the steps in the discharge planning process; list rules and regulations that influence discharge planning in hospitals; and compare hospital-based actions with payer-based actions when planning discharges. Case managers who work for payers interact with hospital-based case managers to facilitate the discharge planning process for patients. Those who form this patient-provider-payer triangle will benefit by reviewing the dynamics of the discharge planning process.

This study focused on case management by examining the relationships between congestive heart failure patient outcomes and nurse structure and process variables. A correlational design with retrospective analysis of data from 175 randomly selected acute care patients was used. The amount of education provided by the nurses on the unit was positively correlated with the degree of pathway completion (r=.32, p =.000) and negatively correlated with the readmissions (r = -.27, p =.000). The degree of completion of the clinical pathway had no effect on length of stay (LOS) but was negatively correlated to readmission rate (r =-.53, p =.000) and positively correlated to hospital days (r =.21, p =.000). Case Management was positively correlated with LOS (r =.41, p =.000) but negatively correlated with hospital days and readmissions, (r = -22, p =.000; r = -.29, p =.000, respectively). No relationships were found between RN hours and LOS or readmissions. The implications of these findings for case managers and nurse administrators are discussed.

This article describes the development of a training model to teach mental health clinicians and case managers about therapeutic boundaries. Awareness of boundary transgressions is vital for establishing and maintaining the moral and ethical integrity of mental health treatment. Our structured teaching model was presented to staff from many different treatment settings throughout our mental health organization. A major portion of each session was utilized for exploration of common boundary dilemmas in the clinical setting as they relate to current policies and ethics codes. Efforts were made to mention the variety of boundary transgressions that may occur in various settings. Participants reported a broadened perspective in their work with clients, having learned about types of boundary issues that they had not previously recognized. Maintaining an understanding of boundary issues among staff requires ongoing educational efforts in training. The health organization's policies on boundaries must be clear and specific to guide the staff. Although training was given in a mental health setting, these lessons can be extended beyond the mental health arena. Safe therapeutic boundaries must be practiced in all settings.

Diabetes places an immense burden on U.S. healthcare delivery systems. The Centers for Disease Control and Prevention estimates the economic impact of diabetes at nearly 100 billion dollars a year. Diabetes affects 17 million people in the United States and ranks as the sixth leading cause of death. Diabetes is among the most psychologically and behaviorally demanding chronic medical illnesses and the presence of diabetes doubles the odds of comorbid depression. In addition, recent research demonstrates that depressive symptoms serve as a predictor of type 2 diabetes. Case managers should maintain a high index of suspicion for the possibility of depression in chronically ill clients, as the severity of depressive symptoms is associated with poorer treatment adherence and higher healthcare costs. Three valid and reliable tools available to support depression screening in the case management setting are presented.

This is the first in an intermittent series highlighting different types of clinical decision support tools utilized by case managers and others involved in strategic healthcare management.

Changes in the Canadian military healthcare structure, and an increased reliance on the public healthcare sector, resulted in care fragmentation and a growing dissatisfaction among members with the quality of health services. To remedy the situation, the Canadian Forces began a major re-engineering of its healthcare services. A component of this reform was the implementation of a case management program to improve the continuity of care for members with complex or chronic medical conditions. Member satisfaction surveys revealed that the case management program meets their needs.

Background Chronic obstructive pulmonary disease (COPD) is one of our nation's most rapidly growing chronic health conditions. It is estimated that over 16 million individuals are diagnosed with COPD (Friedman & Hilleman, 2001). In addition, another 16 million are misdiagnosed as asthma or not diagnosed at all. COPD is a condition that affects the working-age as well as the elderly. Despite the high mortality rate, COPD is a treatable and modifiable condition. Disease management programs (DMPs) for asthma are a common initiative within many health insurance plans and integrated delivery networks. Similar initiatives are not as common for COPD. This article will highlight the National Jewish Medical and Research Center's COPD DMP interventions and outcomes. Objective To outline interventions and operational strategies critical in developing and operating a sustainable and effective disease management program for COPD. Conclusions Disease Management is an effective model for managing individuals with COPD. Applying a case management model that includes (1) risk-identification and stratification; (2) education and empowerment regarding self-monitoring and management; (3) lifestyle modification; (4) communication and collaboration amongst patients, healthcare providers, and case managers to enhance the treatment plan; (5) providing after-hours support; and (6) monitoring care outcomes is crucial. Applying these interventions in a credible manner will improve the quality of life and quality of care delivered to individuals with mild, moderate, severe, and very severe COPD. Additionally, these interventions can significantly reduce utilization events.

This article describes a collaborative approach to manage patients with heart failure between a home care agency and a care management agency. The resulting disease management program used a combination of home visits and phone contact. Care management plans emphasized patient education on increasing adherence to medical and diet regimens, and recognizing early symptoms of exacerbation that could lead to rehospitalization. Clinician activities and patient outcomes are described.

Care of patients who have sustained a mild traumatic brain injury (MTBI) requires collaboration between the case manager, other disciplines, the patients, and their significant other. The case manager's knowledge of the evaluation tools that may be used to assess patient status in various phases of care is essential in planning and dealing with possible variances of care, which could affect outcomes of care. An overview of the etiology of MTBI, diagnosis, recovery, evaluation at various stages, outcome measurement, and examples of valid and reliable tools are presented.

Due to advances made in medicine and healthcare, older adults are living longer but enduring problems with physical functioning and health over longer periods of time. In addition, the percentage of older adults with cognitive impairments is increasing. Caregiving duties, which decades ago lasted for months, now last for years. This long-term strain of caring for an older adult who is physically and/or cognitively impaired may lead many caregivers to feel frustrated, angry, overwhelmed, and isolated. As a result of this stress many caregivers resort to nursing home placement. The Caregiver Options Program and Evaluation research project was undertaken to provide service options to participating caregivers to alleviate some of the debilitating stress associated with caregiving and postpone institutionalization. Results of logistic regression indicate the predictors of nursing home placement were whether the caregiver felt she/he had provided good care, and whether the elder had a problem with household tasks and/or woke the caregiver or other family members up during the night. Findings suggest that elderly care receivers who are predominately low-to-middle income have a physical and/or cognitive impairment, along with their caregivers, need to be especially targeted for help by case managers early in the caregiving process before placement becomes the only alternative.

Management philosophy and culture of any organization must match the nursing professions' core value of caring. Organizational conflict symptomology includes communication barriers and widely differing values. Employment of accountability based systems and bringing nurses into governance prevents conflict and improves job satisfaction. This article identifies the barriers to case management program development and discusses strategies for its successful implementation. Today's most successful organizations will implement an institution-wide commitment to a culture within which excellence flourishes. Creative staffing models and professional practice partnerships such as nursing case management will be supported and encouraged by executive leadership; they work as a team and will be jointly accountable for positive outcomes The United States Army Nurse Corps has the framework necessary to develop a premiere nursing organization. Case management departments may adopt these techniques to improve working relationships and leadership capacity within their organizations.

While the benefit of a health-focused paradigm is clear theoretically, the transition is tortuous. This article reviews the difficulties of implementing the paradigm shift presented in the preceding article. This article presents counteractions, clarifies underlying assumptions, presents the need for collaborative action, and highlights the potential contribution of case management to the paradigm shift.

Recent shifts in the healthcare system reflect a shift in thinking from sickness to wellness. This article reviews the paradigm shift, incentive system, and issues related to cost and quality. The role of case management in facilitating this transition is discussed. The article concludes with a discussion of the challenge to use nursing's unique disciplinary perspective that is focused on health to develop new approaches and strategies and the opportunities for case management to expand its scope of practice.

Cardiac rehabilitation (CR) can help patients with heart disease control some risk factors, limit new coronary artery lesions, and decrease death rates. However, participation rates in CR are low. Using a descriptive design, we evaluated a modified CR program in which nurse care managers used telephonic communication with patients in their homes by comparing it to a traditional CR program in a hospital setting. Using multivariate analysis we compared the patient cohorts eligible for each of the programs, and program participants to the nonparticipants for each program. Compared to traditional CR, the modified CR program with nurse care management was associated with significantly improved participation rates (11% vs. 22%) and the apparent overcoming of several well-described barriers to CR participation (distance from the hospital and domestic isolation). Risk factor management, including testing of serum lipids and achieving goals for lipid reduction, for participants in both CR programs was superior to risk factor management for nonparticipants.

The purpose of this project was to design and implement a case management framework for the benefit of children diagnosed with an autistic spectrum disorder (ASD). The process consisted of selecting two children exhibiting symptoms of an ASD and managing them across a continuum of care. Methodological structure was derived from case management standards of practice and Orem's Nursing Theories. Although some objectives sustained a slight delay because of variances, findings revealed successful outcomes based on progression toward measurable case management goals. The children were directed to appropriate school placements and habilitative therapies in an efficient manner. Their parents received support and education related to special needs children. The process yielded assurance that Orem's Nursing Theories and case management concepts articulate seamlessly within nursing care boundaries.

Case managers are at the forefront of managed care as they seek creative ways to advocate for the best interests of patients, while adhering to the increasingly stringent utilization guidelines and cost constraints of managed care. Nurse care managers are in the ideal position to act as effective advocates because they have the skills needed to "work the system" both within and outside the hospital to ensure that the patient's needs are met.

HIPAA regulations grant special status to psychotherapy notes, placing greater restrictions on their use and disclosure versus other information in a patient's record. Regulations specifically prohibit health plans from requiring the disclosure of psychotherapy notes in their consideration of health claims. However, this issue is surrounded by much confusion. If the information in psychotherapy notes is found only in the psychotherapy notes, it is protected under this provision. However, information that rightfully belongs in the more accessible part of the record is not considered part of psychotherapy notes. In addition, there are certain circumstances in which a provider may be required to disclose psychotherapy notes. This article discusses the definition of psychotherapy notes under HIPAA, comments on the relevance of psychotherapist-patient privilege, and provides important information for the case manager when managing psychiatric patients.

The case management process is a critical management and operational component in the delivery of customer services across the patient care continuum. Case management has transcended time and will continue to be a viable infrastructure process for successful organizations in the future. A key component of the case management infrastructure is information systems and technology support. Case management challenges include effective deployment and use of systems and technology. As more sophisticated, integrated systems are made available, case managers can use these tools to continue to expand effectively beyond the patient's episodic event to provide greater levels of cradle-to-grave management of healthcare. This article explores methods for defining case management system needs and identifying automation options available to the case manager.

The use of case management plans has contained cost and improved quality of care successfully. However, the process of developing these plans remains a great challenge for healthcare executives, in this article, the author presents the answer to this challenge by discussing a 10-step formal process that administrators of patient care services and case managers can adapt to their institutions. It also can be used by interdisciplinary team members as a practical guide to develop a specific case management plan. This process is applicable to any care setting (acute, ambulatory, long term, and home care), diagnosis, or procedure. It is particularly important for those organizations that currently do not have a deliberate and systematic process to develop case management plans and are struggling with how to improve the efficiency and productivity of interdisciplinary teams charged with developing case management plans.

Case management programs are a common approach to managing the quality and cost of services in managed care organizations. Once developed these programs may grow stagnate as the managed care member population grows and changes. This article presents a redesign project initiated by a managed care organization located in a rural Southwest region of the United States. Nursing theory and case management standards of practice form the basis of the redesign project and will be discussed. The case management model, including roles and responsibilities of staff, are presented. Results and future implications are identified.

Studies tell us that most people fear a protracted, painful death; unfortunately, this is what many experience. Palliative nursing care seeks to change this. This new series challenges nurses to think differently about caring for people when cure isn't possible.

There is no uniformly accepted social work case management treatment model for use with impoverished consumers of social welfare services. Differences in intervention models vary greatly across the spectrum of social welfare agencies. There is even marked variance among providers within these agencies. This article summarizes the results of a study of the effects of an empowerment model with public welfare consumers based upon task-centered case management practice. The results of this intervention were assessed over a period of 7 months using ten professional social workers and a sample of 174 public social welfare consumers. The basic research design was a two-group field experiment. Community adjustment was conceptualized and operationalized along eight problem areas. Repeated measures, multivariate analysis of variance identified improvement in six of eight areas of community adjustment when the task-centered case management model was implemented. Given both time parameters and required outcomes of the efficacy of welfare reform under the 1996 Personal Responsibility and Work Opportunity Reconciliation Act, the task-centered model facilitates rapid involvement of public welfare consumers with a systematic, outcome-oriented process.

A model of emergency department (ED) case management consisting of a social worker and a nurse case manager can prevent inappropriate admissions, improve discharge planning, decrease cost, and enhance patient satisfaction.3 The individual and combined roles of the dyad team of social worker and nurse case manager are discussed. A literature review includes how a case management dyad team of social worker and nurse case manager in the ED can decrease utilization of the ED for nonemergent visits, promote the use of community resources, and improve discharge planning to avoid excessive costs. The importance of the dyad team working with the interdisciplinary team in the ED, the primary care physician (PCP), and other community health care providers in order to provide a holistic approach to care is addressed. A discussion about the improvement of both patient and staff satisfaction demonstrates the results of case management strategies that support and advocate for patients to receive quality, cost-effective care across the health care continuum, while decreasing the use of the ED for nonemergent care.

In support of the Veterans Health Administration commitment to the promotion of shared decision-making between providers and patients, this study investigated the relationship between the provision of a patient appointment guidebook, designed to promote and support patient participation in the health care visit, and patient perceptions of primary care visit effectiveness. This study compared perceptions among 277 randomly selected patients randomly assigned to one of two groups. Patients assigned to an intervention group received a patient appointment guidebook along with the standard appointment reminder letter prior to the scheduled routine visit. Patients assigned to a control group received only the standard appointment reminder letter. Patient perceptions were assessed with a follow-up questionnaire designed to measure patient agreement with six statements pertaining to primary care visit effectiveness. No significant differences were noted in the proportion of patients in the two groups that agreed with any of the six statements pertaining to primary care visit effectiveness. Significant differences were noted, however, in the proportion of patients in the groups who received preventive health care interventions of influenza vaccination, pneumococcal vaccination, and gender-specific cancer screening. Approximately 37% of the patients in the intervention group provided positive comments about the patient appointment guidebook, while only 7% provided negative comments. Although statistically inconclusive, the narrative comments indicate that a patient appointment guidebook may assist veterans in preparing for primary care appointments. The lack of significant difference between the two groups on the measures of primary care visit effectiveness may be due, in part, to positive perceptions among the sample in general, as reflected by high levels of agreement and predominantly positive comments for both control and intervention groups.

The authors describe a study of rural case managers' role perceptions. Although various studies have investigated the role of the case manager, no study has examined the role in a rural environment. Survey data and focus groups are used to determine information about the role. Nurses identified differences and problems associated with the case management role in the rural environment. Respondents in the study also identified changes in role expectations, essential clinical skills for rural case managers, and ways in which case management affects healthcare outcomes for rural clients. Essential elements of content for educational preparation of these case managers are also investigated.

Case management guidelines are an integration of information obtained from research, observations, clinical experience, and judgments of expert clinicians, scientists, and clients. This guideline integrates information from multiple practice guidelines in order to guide the case manager in managing clients with Alzheimer disease and other dementias. The guideline provides direction in recognition of symptoms or triggers, risk factors, possible complications, case management outcomes, barriers to effective outcomes, goals, providers/practitioners, treatment options, location of treatment, estimated cost of treatment, psychosocial issues, life planning and long-term planning, vocational issues and teaching protocols. In addition, resource contacts and sources for major instruments used in measuring Alzheimer disease and dementia are presented.

The purpose of this article is to illustrate the role of a patient resource manager in an academic healthcare organization which has implemented a strategy management system. This management system is composed of communication tools organized in a balanced scorecard to support/promote ongoing growth and development using Kaplan and Norton's Strategy Management System. The historical development of Duke University Health System (DUHS) is presented articulating the mission, vision, and strategic agenda of the DUHS with the Clinical Service Unit initiative and its relevance to Women's Services. Kaplan and Norton's 5 core principles of the strategy management system are applied to Women's Services with implementation and evaluation of the patient resource manager role. Moreover, outcomes are discussed using the Balanced Scorecard. Lastly, implications and recommendations for replication of this system are summarized for ongoing development in this continuous learning organization.

The purpose of this study was to determine which variables may discriminate between a short length of stay (LOS) and a long LOS and readmission within 30 days among heart failure (HF) patients discharged from a hospital. The charts of 188 patients who were discharged with diagnostic related group 127 during September 30, 1997, until October 31, 1998, were retrospectively reviewed to examine the association between LOS and readmission among 12 variables. It was discovered that an increased number of physicians involved during the patient's hospitalization (p = 0.000) and case management involvement (p = 0.007) were discriminating variables for those patients with a longer LOS. The variables of serum sodium (p = 0.032) and higher NYHA classification (p = 0.018) approached significance in discriminating a longer LOS. HF patients who were readmitted within 30 days were significantly found to have an increased NYHA class (p = 0.002) and no specific follow-up plan arranged related to the patients' HF diagnosis (p = 0.005). The results of this study indicate several variables that significantly discriminate LOS and readmission within 30 days among HF patients that case managers can employ to improve care to this population.

This article discussed ways for nurses and case managers to address the challenges of providing care to medically complex patients. By focusing on early identification of patient needs, appropriate referrals can be made by nursing personnel to case management. Nurses are able to impact the outcomes of the patients on a daily basis. However, time and resource constraints often leave nurses with limited ability to provide discharge and follow-up services necessary for complex medical patients. Ideally, nursing and case management can work together to address the entire continuum of care needed by these complex patients. Recognizing how and when to integrate these two professionals in caring for specific types of patients can be challenging. The case studies presented in this article should assist the reader in identifying role expectations and potential patient outcomes. The reader is encouraged to share these case studies with others in the organization struggling to develop and/or integrate nursing and case management services in a seamless process. By recognizing and supporting each other, nursing personnel and case management staff are able to become the advocates that patients need and deserve in order to obtain optimal care.

Clinical pathways have been designed to provide an effective interface between evidence and practice in healthcare. Strong evidence supports the assertion that when clinical pathways are utilized they improve outcomes. However, published evidence measuring the uptake of clinical pathways by health professionals remains sparse. This article presents a study evaluating the degree of documented compliance with the clinical pathway chart used for patients diagnosed with an acute myocardial infarction (AMI) in a major Australian regional hospital. The relationships between compliance and demographic and illness were also examined. Data were collected from 124 records with the result that the level of documented compliance was 16.5%. Clients with private health insurance had significantly higher documented compliance with the clinical pathway than those with no private health insurance. There were also significant variations in documented compliance according to the type of AMI recorded. Recommendations to improve compliance with clinical pathways are included along with recommendations for future research.

The influenza season affects not only the people afflicted with influenza, but the healthcare system as a whole. An estimated dollar 12 billion is the annual cost to care for these patients. An existing problem is that although there is an immunization for influenza, many patients at high risk are not immunized. This article will describe an innovative program of a large Midwest suburban hospital to immunize patients at high risk.

This article reviews the physiological and nutritional changes associated with aging and provides the case manager with nutrition resources. General information on nutritional factors associated with aging, including common nutrient deficiences, is outlined. The dietitian's role in nutrition assessment, intervention, and outcomes is discussed. A list of resources for case managers interested in accessing a registered dietitian is also included.

Nursing case management is a blend of individual case- and/or disease-management activities used in urban hospitals or community health settings. The authors propose that in rural communities, a third form of case management is also used. Nursing case management in the rural community has a broader and more diverse scope of practice than nurse case managers practicing in urban settings.

Chronic disease management requires a clear vision, collaboration, and continuing program development to be successful. The patient benefits from an approach that is patient-centered and goal directed. Our challenge in this environment of declining healthcare reimbursement is to stay the course and continue measurement of our outcomes to determine our success in meeting our goals.

Case management programs need to be evaluated for outcomes achievement and efficient use of resources. As a provider intervention, case management is interactional and situational. Little is known about how to measure the actual dose delivered in order to assess quality and manage outcomes. Case management is interdisciplinary, has identifiable dimensions, and serves as a practical example of conceptualizing and measuring the dosage of a provider's intervention. The basic elements of the dosage of an intervention are amount, frequency, duration, and breadth. A three-dimensional model illustrates dosage of case management.

Urinary Tract Infection (UTI) is the second most prevalent complication at Lehigh Valley Hospital and Health Network, occurring in 3% of all patients admitted over a 12-month period and contributing to a significant increase in costs. Utilizing data from CareScience's Care Management System, an online decision support tool, in conjunction with hospital laboratory data, and without manual chart review, approximately 20% of all UTIs diagnosed were found to be potentially nosocomial, and were often treated with an expensive broad-spectrum antibiotic. A multidisciplinary hospital committee developed interventions to study and address these findings. The National Nosocomial Infection Surveillance program was initiated on selected units of the hospital; strict catheter placement guidelines and a postoperative urinary retention protocol were developed to minimize catheter use and dwell time, a cost-benefit analysis was conducted, antibiotic use for UTIs was evaluated, and system-wide education was conducted for physicians, residents, and nurses.

Ruptured abdominal aortic aneurysm (AAA) is the 13th leading cause of death in the United States. Diagnosis is the key to prevention of death from AAA. Millions of Americans harbor this silent, potentially lethal aneurysm. For over 50 years, conventional open surgical repair has been performed for ruptured aortic abdominal aneurysm. It is a major operation with an extended hospital stay and recovery period. An alternative approach to AAA repair has evolved over the past 10 years that combines advances in catheter and stent technologies. With the AAA aortic stent graft, patients usually do not require intensive care and are discharged home within 48 hours of the procedure. This article describes the AAA aortic stent graft procedure, in the formation of a case management team to develop a clinical pathway and standing orders for these patients and defines the outcomes of care.