In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of case management in order to:

  • Explore resources available to assist the client with achieving or maintaining independence
  • Assess the client's need for materials and equipment (e.g., oxygen, suction machine, wound care supplies)
  • Participate in providing cost effective care
  • Plan individualized care for client based on need (e.g., client diagnosis, self-care ability, prescribed treatments)
  • Provide client with information on discharge procedures to home, hospice, or community setting
  • Initiate, evaluate, and update plan of care (e.g., care map, clinical pathway)

The definition of case management and the role of the "case manager" vary greatly in the professional literature. As discussed with critical pathways in the integrated process entitled "Communication and Documentation", case management is method of nursing care delivery, however, case management can also be used to describe the roles of people who work in health insurance companies, the roles of people, like social workers, who work in healthcare facilities to move clients along the continuum of care, and as of the many roles of that nurses have.

The registered nurse as a case manager entails the coordination of care, resource identification, the planning of services, referrals, and linking clients to the services that they need as based on their biological, emotional, and social needs as well as their spiritual and cultural preferences.

Registered nurses, as case managers of care:

  • Insure that client care is of high quality, effective, timely, complete and cost effective
  • Insure that all clients are provided with the care and services offered by not only the appropriate members of the nursing care team but, also, with members of the multidisciplinary healthcare team such as a physical rehabilitation team or a community home care team, for example. This aspect of case management is accomplished by connecting, referring and linking clients to the services that they need as based on the kinds of care and the levels of care that they need according to their current assessed needs.
  • Insure that all clients are provided with the material resources that they need to meet their current assessed needs. For example, the client may need a CPAP machine, a sequential pressure device, oxygen therapy and oxygen supplies, a suctioning machine and/or sterile wound care supplies including sterile dressings
  • Coordinate and continuously evaluate the timeliness, effectiveness and appropriateness of client care
  • Identify and implement immediate and effective actions if, and when, any deviations from the plan of care and/or poor patient outcomes occur
  • Insure that the client is at, or moved to, the appropriate level of care, as indicated by the current client's status, so that appropriate care at the appropriate level of care can be provided and also to insure that insurance reimbursement for their necessary care and services is done

Case management, as previously mentioned, is also a formal method of nursing care delivery. In this context, case management can employ a number of different frameworks and models. These possible case management models used for patient care delivery systems include:

  • The ProACT Model
  • The Collaborative Practice Model
  • The Case Manager Model
  • The Triad Model of Case Management

The Professionally Advanced Care Team, abbreviated as and referred to as the ProACT Model, of patient care delivery was developed at the Robert Wood Johnson University Hospital. This model, simply described, assigns and addresses the registered nurses' role as both a primary nurse providing clinical care and a clinical case manager with additional formal functions such as those related to personnel, fiscal and budgeting responsibilities and administration/management functions.

The Collaborative Practice Model of case management entails the role of some registered nurses in a particular healthcare facility to manage, coordinate, guide and direct the complex care of a population of clients throughout the entire healthcare facility who share a particular diagnosis or Diagnostic Related Group, referred to as a DRG, such as chronic obstructive pulmonary disease, an acute myocardial infarction or the Tetralogy of Fallot.

The Collaborative Practice Model of case management uses the critical pathways, also referred to as clinical pathways, as were previously discussed. This model also identifies, monitors, tracks, trends and documents all variances including patient related variances, healthcare provider variances and system variances.

The Case Manager Model or The Beth Israel Multidisciplinary Patient Care Model is quite similar to the Collaborative Practice Model with the exception of the fact that this model, unlike the Collaborative Practice Model, is unit based and not organization wide. For example, a registered nurse on a particular nursing care unit may be assigned to take care of all of the clients on that unit who share a particular diagnosis or Diagnostic Related Group; these nurses remain on their unit rather than having clients throughout the particular facility like the nurses using the Collaborative Practice Model do.

The Triad Model of Case Management, also referred to as the Collaborative Care Model of Vanderbilt University Medical Center in Nashville, Tennessee creates, maintains and focuses on the close interdisciplinary collaboration of the social worker, the nursing case manager, and the utilization review team member throughout the course of care.

Exploring the Resources Available to Assist the Client with Achieving or Maintaining Independence

All available resources, including available human, material and financial resources, must be explored, identified and garnered in order to promote optimal patient care outcomes and to assist the client with achieving and maintaining their highest possible level of independence.

Nurses manage client care, as a case manager; strive to insure that the client receives the correct resources at the correct time and in a timely manner. When goal is not accomplished in an effective and timely manner, the healthcare facility loses money and/or optimal outcomes are not achieved.

All possible resources that could possibly assist the client with achieving and maintaining independence, as based on the assessment of the client and their current needs, are explored, after which the best possible and most feasible alternative(s) is (are) selected and employed. After this intervention, the registered nurse evaluates the successes or failures of these interventions in terms of how well they have facilitated client independence or any other expected or desired client outcome or goal or they have failed to do so. When expected outcomes are not achieved, the registered nurse determines the reason(s) behind this failure.

Assessing the Client's Need for Materials and Equipment

After the client is fully assessed initially and then also reassessed in an ongoing manner, the nurse, as the manager of care determines which supplies, materials and equipment the client needs to meet their needs.

After this assessment and determination, the registered nurse then Insures that the client is provided with the material resources, including supplies and equipment that they need to meet their current assessed needs. For example, the client may need a CPAP machine, a sequential pressure device, oxygen therapy and oxygen supplies, a suctioning machine and/or sterile wound care supplies including sterile dressings

Participating in Providing Cost Effective Care

Nurses and other members of the healthcare team, often in a collaborative manner, plan care as based on is appropriateness, its cost effectiveness and its cost/benefit benefit ratio without compromising the quality of care and/or optimal positive outcomes of care. The challenge lies within. The nurse, and others, must select the treatments, interventions, and human and material resources that are the least costly and ALSO the most beneficial and the most appropriate.

Cost effective is defined as "giving the most profit or advantage in exchange for the amount of money that is spent" and the cost-benefit ratio is defined as the "comparison of the likely costs of a plan or project with the benefit it will bring, done in order to help make a decision". Cost effective care and the care and services provided to clients with a good cost-benefit ratio is NOT always the least expensive and the least costly. Nonetheless, this care and services must be the least costly possible while still high quality and effective in terms of meeting the clients' needs.

According to the US Centers for Medicare and Medicaid Services (CMS), "In 2014, U.S. health care spending increased 5.3 percent following growth of 2.9 percent in 2013 to reach $3.0 trillion, or $9,523 per person. The faster growth experienced in 2014 was primarily due to the major coverage expansions under the Affordable Care Act, particularly for Medicaid and private health insurance. The share of the economy devoted to health care spending was 17.5 percent, up from 17.3 percent in 2013." Health care is costly and its costs continue to rise.

In the not too distant past, healthcare facilities, including hospitals and medical centers, were reimbursed for the services and care that they provided based on the cost associated with these services. This type of healthcare reimbursement was referred to as retrospective reimbursement. Under retrospective reimbursement, there was little or no reason or incentive to control and contain costs because insurance companies paid for all the provided care and services regardless of their associated costs. As healthcare costs continued to rise and spiral out of control, cost containment efforts led to the discontinuation of the retrospective reimbursement system and the rise of the prospective reimbursement system.

As the result of prospective reimbursement, healthcare facilities and healthcare providers no longer got reimbursed for all the care and services provided. Instead, they got, and remain to be, reimbursed at a fixed amount as determined by the client's specific diagnosis related group (DRG). As a result of this retrospective reimbursement system, healthcare facilities that can successfully and effectively provide quality care that insures optimal outcomes with shortest possible lengths of stay and the fewest possible resources and care make more money than those with extended and prolonged lengths of stay and the use of unnecessary, abundant, and unlimited resources. Cost containment became, and remains to be, a high priority for healthcare organizations and healthcare providers.

Healthcare insurance companies, also referred to as third party payers, in our nation include governmental health care insurance and private healthcare insurance companies.

The United States Medicare program and the states' administered Medicaid programs are the two governmental reimbursement programs. Medicaid reimburses healthcare costs for low income individuals, low income families, and chronically ill and disabled children. Medicaid is administered by the states. Medicare, under the U. S. Social Security Act, reimburses healthcare costs for older adults who are 65 years of age and older, as well as permanently disabled people and their dependents.

Private insurance companies differ in terms of their monthly premiums, their annual deductibles which the healthcare insurance policy holder must pay, their copayments which the healthcare insurance policy holder must pay, their covered services, and reimbursement rates.

Planning Individualized Care for the Client Based on Need

All care is planned as based on the needs of the unique individual and their needs, their diagnosis, their level of self care abilities, their strengths, their weaknesses, and treatments that are ordered and prescribed.

The planning process was previously detailed and discussed with the "Integrated Process: The Nursing Process".

Providing the Client with Information on Discharge Procedures to the Home, Hospice, or Community Setting

Like initial planning, discharge planning should, and must, begin, as previously stated, at the time of the first client contact and/or immediately upon admission to a healthcare facility.

Discharge planning must reflect the needs of the client at the appropriate level of care along the continuum of care. For example, a discharge plan may include a discharge to the client's personal home, to a physical rehabilitation center or a discharge to the client's personal home with the services of a home health company. This planning can also include other discharges in the community such as a hospice and palliative care center, a long term care nursing home or an assisted living facility.

Failures to effectively plan discharges along the continuum of care fragment and jeopardize the well-being of the client. They are also quite costly and highly avoidable when continuous, ongoing assessments and discharge planning is complete and accurate.

As part of the discharge planning process, registered nurses in collaboration with others, use established medical necessity criteria to determine and to confirm that the client is being moved along the continuum of care at the appropriate level of care and also to confirm that the client is being provided with only those services and care that are consistent with these established criteria. Only care that meets these criteria will be paid for and reimbursed for.

Initiating, Evaluating, and Updating the Plan of Care

As previously stated, the purpose of a plan of care is to insure that the client is getting appropriate, complete and timely care as based on the current needs and status of the client. For this reason, all clients must have a current plan of care that is initiated, evaluated in terms of its appropriateness, effectiveness, completeness and timeliness.

The plan of care, or care plan, whether or not it is a traditional care plan, a care map, or a critical pathway, MUST be updated and remain current as based on the client's current needs.


SEE – Management of Care Practice Test Questions

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