人民医院总体发展战略咨询Hospital-Based Case Managemen

总结：病案管理是管理涉及多领域的治疗活动、以及按病案的类型和诊断相关的特定医院的病人群体的相应资源的一种工具。

它平衡治疗的实施与成本以期为病人达到满意的治疗结果，特别是那些不能按常规的处理流程治疗的病人。

来源是面临个方面降低成本的压力。

Hospital-Based Case Management: Part IGeorge Byron Smith, RN, MSN, CCM Debra Ann Danforth, RN, BSN--------------------------------------------------------------------------------The goal of this program is to explain hospital case management and its benefits to professional nurses. After you study the information presented here, you will be able to —List three goals of case management in acute care hospitals.Identify three common characteristics of an effective case management system.Identify two benefits of case management in hospitals.--------------------------------------------------------------------------------Leonard Boyd is admitted directly from the emergency department to a critical care unit with a diagnosis of congestive heart failure (CHF). His nurse immediately initiates the CHF clinical pathway and during the first two days he progresses as expected. However, Mr. Boyd develops unanticipated complications on the third day. The nurse calls the case manager (CM), who convenes a meeting with the multidisciplinary care team. The team discusses the patient’s current status and expected outcomes, and develops a revised plan of care to deal with this patient’s specific deviations from the usual course of events. During the rest of the hospitalization, the CM will evaluate Mr. Boyd’s progression on the clinical pathway and will document any variance from expected patient outcomes. The CM will also work with the team to ensure that their interventions both maintain quality and maximize the use of resources in his care.（案例）Hospital-based case management is a tool for managing the multidisciplinary care activities and resources for specific hospital patient populations classified by case-type and/or diagnostic-related group (DRG). It balances the delivery and costs of care to achieve desirable outcomes for patients, for those patients who are ―predictable,‖ but especially for those who might not follow a usual course of events during their hospitalization.This innovation is a response to pressures by Medicare, insurance companies, and managed care companies on behalf of self-insured employers to reduce the cost of care. Care is reimbursed by all-inclusive, global payments, such as by DRGs, capitation (where the hospital or health care organization is paid a per subscriber, per month fee to cover all healthcare expenditures, no matter what the cost of care), or stringent per-diem rates. The insurance companies deny reimbursement for hospital days used in excess of the expected norm. The expected norm has steadily decreased over the past five years.Sicker hospital patients, who require more labor intensive nursing care and more expensive tests, treatments, and other hospital services, have created a demand for better systems to manage finite resources. This has pushed hospitals to implement innovative systems to enhance both quality and cost-effectiveness. The challenge of placing patients in the appropriate level of care also exists with an increase in complexity of patients.In hospitals, nursing care is often managed by a unit-based delivery system that is organized to achieve specific patient outcomes within cost-effective time frames with the appropriate resources. This care system is structured by case management and clinical pathways or similar protocols that outlin e ―best practice‖ care for subsets of patients. When a patient’s progress deviates from the expected course, a case manager and a multidisciplinary team converge to redirect the course of care.Case management has flourished because it addresses the requirements of nurses and physicians, third-party payers, and hospital administrators by controlling the relationship between quality and cost. By providing a system for coordinating care and reducing fragmentation among multiple services and caregivers, cost is decreased. Ideally the system monitors the continuum of illness from preadmission to postdischarge.New Methods for Old GoalsTraditionally, physicians, nurses, physical therapists, dietitians, and other caregivers developed separate plans for patients, documenting in individual sections of the medical record and communicating minimally with one another. Such uncoordinated efforts have sometimes resulted in contradictory plans and goals that countered the efficient delivery of care.Case management cuts across departmental lines and allows hospital groups to meet frequently to plan and track patients’ progress. Disciplines become more aware of each group’s interventions and how their actions affect one another and patients. Individual interests are merged into one collaborative plan to achieve mutual goals.This model places a new emphasis on involving patients and their families in their own care by keeping them informed about their progress and anticipated outcomes. Patient care, standardized for each medical diagnosis, includes a significant patient education component.By bringing all disciplines together with their patients, case management helps acute care institutions to simultaneously control the quality of care and the cost of providing it. Other projected outcomes include:Reduced lengths of hospital stay.Improved continuity of care.Increased participation and satisfaction of patients and families.Enhanced satisfaction of physicians, nurses, and support services personnel.Improved communication, cooperation, and coordination within and among disciplines, and across care areas.Efficient allocation of resources.Decreases in payment denials by insurers.Improved communication with payors.Origins of Case ManagementEarly case management-type models were developed in public health, mental health, and long-term care settings. Community service coordination programs of visiting nurses appeared in the early 1900s, when nurses managed their own individual caseloads.1 Workers’ compensa tion insurance companies have used rehabilitation nurses as case managers since the late 1940s. Major medical insurance companies also have used nurses to coordinate the care of high-dollar cases (using the term ―large case management‖). Following World Wa r II, an emphasis on supporting mental health patients in the community developed and continued through the early 1970s.2 Providers offered extended services to follow psychiatric patients after discharge through the entire ―continuum of care,”a concept fundamental to later case management.The term case management first appeared in the literature of social welfare in the early 1970s.3 The New England Medical Center (NEMC) in Boston, MA, has been credited with pioneering today’s hospital-based case management.4 The New England Model expanded concepts from primary nursing and remains a standard for other hospital-based programs. The widespread use of the term case management in hospitals has caused some confusion because the associated practice there is not the same as that of non-hospital case managers. Hospital case managers often have utilization management functions and primarily focus on what happens within the walls of the hospital. Insurance and community-based case managers manage the patients’ care over a wider continuum.In more recent years, the government implemented research and demonstration projects to establish comprehensive case management services at the community level.5 For instance, The 1981 Omnibus Budget Reconciliation Act and the prospective reimbursement of Medicare encouraged community-based alternatives to institutional placement for many patients. Now almost all providers claim that they do case management because they realize they need to more carefully coordinate and manage both care and cost.Common CharacteristicsBecause hospitals tailor case management to fit their own environments and organizational cultures, models appear to be different in each institution. However, there are common characteristics:Standardization — Patient care is standardized either through the use of clinical pathways or some form of prescribed clinical protocols. Clinical pathways are used as care plans to cue the daily activities of hands-on care givers. Protocols outline when day-to-day hospital processes and the interventions of nurses, physicians, and other hospital personnel should occur. Key processes。