Medical Management Guide, 2009, Version 3.0 - Tricare

Page 70Case Management Version 3.0Medical Management GuideDuring monitoring, the case manager:• Ensures timely and appropriate care is providedbased on the patient’s changing health statusand/or environment.• Ensures timely patient/family and healthcareprovider contact and follow-up.• Establishes and documents progress towardsmeeting plan-of-care goals.• Identifies variance(s) from the plan of care andrevises the plan accordingly.• Monitors the result of actions/interventions andcare delivery.• Monitors utilization of healthcare resources.The case manager will continually assess andmonitor the patient’s response and adherence totreatments, and decide whether services shouldcontinue or new services should be implemented. Inthis respect, monitoring dovetails with assessment.Monitoring also includes collecting and trackingdata.6. EvaluationEvaluation is a continuous step in which the casemanager measures the patient’s response to thehealthcare services being delivered. The casemanager uses critical thinking skills to analyze thedata obtained during monitoring and revises theplan of care to respond to the patient’s ongoingneeds.As part of this step, the case manager must make acomprehensive routine assessment of the patient’sstatus and progress toward meeting the goals statedin the plan of care. If no progress is noted, the casemanager should determine the reason and revisethe plan of care to include interventions that willpromote the identified goals.Other measures of care may include patient/caregiver and healthcare team satisfaction, as well ascost savings.Case ClosurePlanning for case closure begins at the time thepatient is accepted into CM. The consistent goaland measure of success of a plan of care is that thepatient/caregiver(s) be able to self-manage — thatis, to advocate for themselves. Early in a case, it isappropriate for a case manager to make referrals,contact providers, and research resources. As thecase progresses, that responsibility needs to betransferred to the patient/caregiver(s), as appropriate.As the case manager works with the patient/caregiver(s), he/she acknowledges successes in thepatient’s progress toward greater self-sufficiency.As the case manager assesses a patient’s progresstoward meeting the goals established in the plan ofcare, the case progresses toward closure.Sometimes not all goals are achieved. A case mayappropriately be closed based on circumstances suchas failed adherence to treatment regimes, changein eligibility, or even death. In some circumstances,it may be useful to conference with another casemanager in making the decision about whether toclose.When the decision to close a case is made, the casemanager undertakes the following steps: