Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 68Case Management Version 3.0Medical Management GuideGoals/outcomes must also reflect input from theentire healthcare team.• Goals for the individual patient are defined aftera thorough patient assessment is completed.At that point, the case manager addresses theproblems that have been identified. Goals/outcomes are defined based on the resolutionof those problems.o For example: Patient A needs specialtycare that is not readily available in thearea where he/she lives. The goal is toprovide access to the needed specialist.The case manager's interventions aretargeted toward linking the patient withthe specialist in a manner that is accessible,affordable, and reliable. When the linkbetween specialist and patient is validated,the problem is resolved and the goal ismet. The outcome is appropriate and timelyspecialty care, when needed.• Individual goals must be re-evaluated whenpsychosocial, medical, or financial changesoccur. Treatment and plans of care must beadjusted accordingly.Multiple actions/interventions may be assigned inresponse to each barrier; these may include:• Providing research on appropriate and availablespecialists within the MTF/network who canmeet the patient’s medical needs.• Obtaining a list of all medications the patientis taking, including name of prescriber(s) andpharmacy(ies) dispensing the medications.• Requesting referral to a pain clinic.The plan of care must be agreed to by the patientand the PCM, and all parties must sign it. The planshould include contacts for medical/behavioralhealth providers; resources to be explored;verification of medications to be taken; and anassessment of housing needs, transportation, andlevel of caregiver support.The plan of care is meant to optimize Direct CareSystem (DCS) and Purchased Care System (PCS)resources, special health-related programs, and otherfederal/national/state/local agencies and resources.3. ImplementationBarriers may include:• Transportation not being available for patientvisits to a specialist.• Multiple prescribed medications from variousproviders (i.e., polypharmacy), with the patientunable to manage his/her pain.• The patient being unaware of availablecommunity resources.There are usually several barriers associated witheach problem, which in turn serve to further definethat problem.Implementation involves executing actions/interventionsidentified in the plan of care that willlead to accomplishing stated goals. This processstep necessitates communication betweenhealthcare team members, including the patientand his/her family or caregiver(s). At the outset ofimplementation, the case manager should discussthe goals of the plan of care with the patient andhis/her caregiver(s). This includes advising them theywill continue to be a resource for the case manageruntil such time that problems have been resolved
Medical Management GuideVersion 3.0Case ManagementPage 69and goals met — at which point, the patient/caregiver(s) can self-manage.The case manager activates the actions/interventions described in the plan of care, anddocuments the following types of information:• Date(s) of contact.• Who was contacted.• The purpose of the contact(s).• What was discussed.• The outcome of the discussion(s).• The specific plan for next action/intervention,including the scheduled date.During implementation, all elements of CMstandards of practice must be adhered to alongwith other applicable guidelines, including clinicalpractice guidelines (CPGs). The following resourcesmay be useful in this effort:• VA and DoD CPGs: https://www.qmo.amedd.army.mil/pguide.htm.• The Agency for Healthcare Research andQuality (AHRQ): http://www.ahrq.gov/. TheAHRQ has published and disseminated nationalCPGs for more than 19 clinical subjects. Theseare accessible through the National Library ofMedicine’s Medline service: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi.Refer to Section IV, Disease Management, formore information on CPGs.4. CoordinationCoordination involves organizing, securing,integrating, and modifying the necessary resourcesto accomplish the goals set forth in the plan ofcare. This step directs the patient to appropriateservices to achieve seamless and timely continuityof care. Coordination is achieved by identifyingpatient needs and applying appropriate actions/interventions (see also Step 2, Planning).Coordination of activities helps case managers:• Avoid duplication of services.• Ensure timely and appropriate provision ofservices.• Identify barriers to care delivery and exploredelivery alternatives.• Match patient needs with available resources.• Optimize healthcare resources in the MTF andlocal community.• Organize and manage the activities outlined inthe plan of care.• Ensure all care providers receive necessaryinformation in a timely manner.Depending on the availability of services or agenciesin the local area, the MTF case manager may needto coordinate with the MCSC. Access to communityresources from all levels — local, state, and national— will facilitate coordination of services.5. MonitoringMonitoring involves gathering information fromrelevant sources on an ongoing basis with regardto healthcare activities and services, and to patientadherence to the treatment plan. Case managersconduct monitoring to determine whether plannedpatient goals have been achieved and how effectivethe process is for achieving them.
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