1. NURSING CASE MANAGEMENT

2. Introduction Case Management model designed for use in:
population approach
community setting
complex clients (disease management)
We would like to introduce ourselves:
Leane
I am …
Hi my name in Glenyse and I am a public health nurse in the population protection team, Auckland Regional Public Health Service
(Known as arphs)
We are a part of the Auckland District Health Board
Our team covers infectious diseases ranging from food borne illnesses to TB and MenZ B
We would like to describe our case management model which is used by public health nurses in our team because it encompasses:
Population approach
Community settings
Complex clients (disease management)

3. Nurse case management - a strategy for care co-ordination
“ A role and process that focuses on procuring, negotiating, and coordinating the care, services, and resources needed by individuals with complex issues throughout an episode or continuum”
Leane – Nurse case management – a strategy for care co-ordination:
Bower defines this as “a role and process that focuses on procuring, negotiation and coordinating the care, services and resources needed by individuals with complex issues, throughout an episode or continuum”
Leane - Case management is an important strategy in coordinating client care, but it cannot be used in isolation. To be effective, case management must be used in conjunction with other strategies e.g. Collaboration, networking, use of critical pathways/protocols, programme management and resource management. It will then become a focused, cost-effective approach to managing quality, cost and access issues.
Glenyse – The Nurse case management role is founded upon the nurse/client relationship and the use of nursing art and science. The role depends on the use of the nursing processes and fosters the client’s self-reliance.
Bower, K. (1996)

4. Case management
strategy to coordinate care through a process of managing quality, access, and cost to manage the risks with vulnerable groups. (Yoder-Wise, 1999)
It involves face-to-face relationships across a variety of health care agencies and services and their representatives.
Regardless of the setting or wellness level of the client population, case management takes interdisciplinary collaboration, the working together of professionals across health,
education, and welfare domains, moving clients toward specific, measurable outcomes. The nurse works with clients using all available agencies and services to reach predetermined goals.

5. Case management
is an area of practice within several healthcare professions. Most case managers are nurses or social workers.
The term case management is also used to refer to dispute resolution systems which provide court or tribunal officials with closer administrative control over the litigation process than is traditionally associated with common law litigation.

6. Case management
The Case Management Society of America defines case management as:
"a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes."
One does not have to be a nurse to function as a case manager. Most social workers have no clinical component in their background yet function as case managers. Discharge planning is more of a social services discipline; the reason that most hospitals utilize nurses as a case manager is because of the need for utilization review. From a bird's eye view, the CM position is broken down into a few components. 3/4 of the workday is spent doing utilization review, and the other quarter is actual discharge planning.
Most nurse case managers work in hospitals or at health maintenance organizations; some function as independent consultants.

7. Case Management goals:
Enhance health status and functionality of clients;
Maximize client access to services;
Use resources cost-effectively;
Integrate & coordinate services provided by multiple disciplines
Glenyse - Nurse case management seeks to:
-Enhance the health status and functionality of clients with complex health issues
-Maximise client access to health-care services
-Use resources cost-effectively
-to Integrate & coordinate service delivery activities provided by multiple disciplines.
[Cohen, 1996 #26]
Cohen (1996)

8. Five Principles of Nursing Case Management
Focuses on clients and families with complex issues
Involves negotiation, coordinating, and procuring services and resources
Entails using a clinical reasoning process
Network development of multi-disciplinary relationships
Is episode- or continuum-focused
Leane - 5 principles of case management: Cohen sees this as:
Focusing on clients and families with complex issues
Involving negotiating, coordinating, and procuring services and resources needed by the clients and their families
It Entails using a clinical reasoning process – this is especially important in our autonomous practice
It Involves developing a network based on multiple, interdisciplinary relationships
It Is episode- or continuum-focused
[Cohen, 1996 #26]
Glenyse – We thought we would give you a little look into the past. Practice setting: Historical background
Cohen, E (1996)

9. For community health nurses, this has been the method of caregiving for more than 100 years.
However, it was introduced in the acute care setting, with enthusiasm, in the 1990s as a “delivery innovation” and a panacea for harnessing escalating costs and insurance premium increases.
(Powell, 2000)

10. Hospital
The Wellington Hospital Board in 1903 recognised the need for special treatment for patients with TB. They purchase of a property in Otaki. A few patients were sent there to live under canvas.
In 1907, the Sanatorium was opened, a two storied building, & accommodate 19 men & 11 women.
This was later taken over by the Health Department & then by the Palmerston North Hospital Board.

11. Sanatorium An early Sanatorium in Pontsarn Canada.
For those of us that nursed TB clients in the past, we will recognized the large opening windows which were a part of all the old TB wards & the patients being nursed in the open air as it was believed that fresh air & sunlight played a large part in the healing of TB.

12. Community
The mobile chest x-ray bus – these have been used in recent times in Holland
Mobile units have been used more and more in the community today.
In Auckland, a mobile unit was used by public health in 1988 when we had a hepatitis outbreak, the MenzB project used the Plunket bus to reach urban children.

13. Nurse case management in the Community Setting
Health promotion & disease prevention
Prevent escalation of client condition
Comprehensive & collaborative care
Efficient use of health care services
Practice guidelines, clinical pathways & client/family outcomes improve effectivity
Leane - In the area of community health, public health nurses traditionally have practiced health promotion and disease prevention rather than only cure and illness.
This prevents the escalation of an individual’s health condition into a more serious condition.
Public health nurses practice collaborative and comprehensive care rather than short-term interventions.
This coordination of health services and integration of health care delivery creates a more efficient use of health care services.
Practice guidelines, clinical pathways and client/family outcomes can be used for effectivity of services
The unique opportunity afforded by public health nurses adds value both economically and in the provision of comprehensive care’ [Cohen, 1997 #27].
Glenyse - PHNs need to articulate what their expertise is, in regard to case management, so that this can be recognised as an effective strategy.

14. The Case Management Process
Case finding & risk appraisal
Nursing interventions matched against characteristics & needs of the risk group
Co-ordination of services & continuum of care
Evaluation of individual & group outcomes
Bower, K. (1992) & Mullahy, C.M. (1995)
Glenyse –
Our clientele are drawn from the greater Auckland region which covers from Warworth in the north to Mercer in the south & coast to coast
When an identified case of an infectious disease is notified to our team, A risk appraisal is done from a multi-disciplinary team approach including HPO’s, PHMS, PHNs and support staff.
A full assessment and follow up and any contact tracing required, is guided by protocols and nursing best practice guidelines.
The individual is seen as being part of a family, part of a community and, as such, there are many other determinants that impact upon his/her recovery.
Therefore we see the case manager as the key link person to access and co-ordinate care.

15. WIDER COMMUNITY WORK & PLAY WHANAU CLIENT HOSPITAL MO’S/PHMS
NURSE
WORK & PLAY
WHANAU
CLIENT
HOSPITAL
MO’S/PHMS
A pictorial version of the model will look like this:
On the continuum of care of a client with an infectious disease eg TB is referred to the service. The nurse case manager will keep the client/family/whanau at the centre of their care, while co-ordinating their care across from the home – their place of work and play – into the wider community where community development around TB takes place. They co-ordinate care across from primary care into the secondary institutions ie. The hospital – medical officers – public health medicine specialists – other nurses – and various community agencies who may be needed to advance client care eg. WINZ, Housing NZ, TB Association etc.
OTHER PHN’S
SOCIAL AGENCIES
NURSE

16. Strengths Good collaboration – nurse/client/doctors/services
Focuses on prevention
Highlights health promotion
Treatment becomes an integral part of daily life for our client
Leane – Strengths
Good collaboration – nurse/client/doctors/services
Improves compliance
Also Integrates health care delivery systems
2. Focuses on prevention –
Identifies trends and exacerbation of illness identified by clients together with the public health nurse to develop preventative strategies.
Glenyse –
recently one of my clients was complaining of feeling unwell & as I was at the chest clinic that morning I reported this to the chest Physician. Her LFTs were done and as these were abnormal her TB medication was stopped until these return to normal – she will then have a drug challenge……..
3. Highlights health promotion
Promotes a ‘grass-roots’ approach to primary care prevention and low cost management of potentially high – risk populations. Lamb, G. (in press).
4. Treatment becomes an integral part of daily life for our client

17. Weaknesses
Dependent upon individual nurses’ skills/perseverance/initiative
Educational requirements vs the demands of the role
Nurses often feel ill-prepared to offer basic instruction/support in health promotion & prevention
Leane
Some of the weaknesses we identified are that the Dependent upon individual nurses’ skills/perseverance/initiative –
it is known that the average age of the public health nurse workforce is average of 50 yrs. What are the implications of this for the future public health nursing?
Glenyse
Gerri Lamb states that nurse case managers “require knowledge and skill in family and community assessment, risk appraisal and modification, group dynamics and leadership, and programme evaluation”.
Today most of these competencies are addressed in graduate level nursing education programmes.
The lack of adequately prepared nurses may present a serious obstacle to realising the benefits of nurse case management in the community”.
Another weakness we identified is that nurses often feel ill-prepared to offer basic instruction/support in health promotion & prevention

18. Optimum Example
And this is an example of we consider to be an Optimum Example of good nurse case management.

19. Benefits & Outcomes Question:
Where on the continuum do the clients access services?
How do we measure prevention?
How do we measure health promotion?
What changes are needed to realise these benefits?
Leane - These are the questions we have to ask ourselves?:
Where on the continuum do the clients access the services? This is where networking and collaboration are important, and an in-depth knowledge of our community and health services. It is also knowing where to link in with Primary Health Care and the secondary care sevices.
Glenyse -
How do we measure prevention? A good example of this is our BCG programme which is run at MMH and our community clinics throughout the region. Figures indicate that we vaccinate about 7500 at risk babies per year. There were 185 cases of TB in the Auckland region last year (15.4 per 100,000). Just 12 cases were under 15 years of age in 2004.
How do we measure health promotion? – both of these are core business to public health nursing and are very difficult to actually measure – eg as public health nurse we provide education around the risk to others of infectious disease. We do this in the home/workplace/ community settings – the local McDonalds.
As a response to an increasing rate of TB in the Indian community, as train-the-trainers programme was undertaken. This has had a good response from that community who have now owned it as a model of community development.
We give lectures in TB and MCD and hepatitis at tertiary institutes and community groups,
We are supported in our service by the Auckland Chest and TB Association and the Pacific Leprosy foundation – they support us by being able to offer our clients help in ways we cant eg. Financial – pay part of the power bill.
…………..

20. Why measure outcomes?
Dramatic shifts in health care delivery is being driven by changes in reimbursement
It is more cost effective to treat populations by using epidemiological and public health models rather than treating individuals or families/whanau
Leane -
Dramatic shifts in health care delivery is being driven by the primary health care strategy
There is a need to identify high-risk vulnerable individuals and groups before they enter a downward health trajectory and a cycle of using expensive acute care services
Public health and epidemiological models are used to identify commonly occurring and potentially expensive health problems eg polio – the last 2 cases were in 1998 –one in an infant, and an unimmunised mother. (MenzB)
Increasingly the health dollar is being used to manage the health needs of populations rather than individuals and families eg. SARS and now the Avian flu preparations.

21. Challenges in Measuring Outcomes
Client confidentiality
I.T. development of user friendly software
Nurse’s need to adapt health care practice to modern-day technology
Population-based care requires healthcare providers work together
Glenyse -
Client confidentiality:
Need to know vs. right to know. The stigma around the infectious diseases and the perceived risk to other individuals
Measuring client satisfaction in a survey eg. difficult
Leane -
IT development:
Includes developing systems, and structures that provide PHC and preventive services eg. First responders right through to end of continuum of care
Nurse case managers need to adapt their practice to modern-day technology – texting, .
Recognise and track marker events and conditions that signify gaps or failures in co-ordination and preventive efforts (pandemic)
Population-based care requires: Administrators, professionals and stake holders to work together to deliver population-based care. Our question is - How to measure this?

22. Examples of Outcomes Measurement
Quality Outcomes
Cost Outcomes
Comparison studies to show contrast
Measuring the complexity of needs
Glenyse -
We would like to measure anticipated health risk and avert potential complications. In many areas of clinical practice, there is insufficient research to assist nurse case managers to predict individuals and groups who have a high probability of
experiencing adverse events and
responding to nursing interventions in ways that will significantly reduce their risk.
Eg. Change of lifestyles and dealing eg smoking interventions & taking INH for LTBI
Leane -
Part of this session was called “Setting up an evaluation process ” As a team we do not have an evaluation process of this model of case management (We have anecdotal evidence and our own personal experience), and one of the outcomes that we would like to take away from this conference is ‘how to set up an evaluation process’.

23. Lessons Learned Central to this model are: Collaboration Networking
Keeping the client & family/whanau at the centre of care
Public health nurses have become pro-active in the development of strategies that are core to the health care management of high-risk populations eg. Case management
Multi-disciplinary team approaches
National and International planning
Leane -
Central to this model are:
Collaboration
Networking
Keeping the client & family/whanau at the centre of care
Public health nurses have become pro-active in the development of strategies that are core to the health care management of high-risk populations eg. Case management
Multi-disciplinary team approaches
National and International planning

24. Bibliography
Bower, K. and C. Falk (1996). Case Management as a Response to Quality, Cost, and Access Imperatives. Nurse Case Management in the 21st Century. E. Cohen. St. Louis, Mosby:
Cohen, E. (1996). Nurse Case Management in the 21st Century. St Louis, Mosby.
Cohen, E. and T. Cesta (1997). Nursing Case Management; from concept to evaluation. St Louis, Mosby.
Donabedian, A. (1990). “The Seven Pillars of Quality.” Arch Pathol Lab Med 114:
Etheredge, M. L. (1989). Collaborative Care Nursing Case Management. (American Hospital Association), American Hospital Publishing, Inc.
Kersbergen, A. L. (1996). “Case Management: a rich history of coordinating care to control costs.” Nursing Outlook 44(4):
Zander, K. (1990). Patient Care Delivery Models. Rockville, MD: Aspen Publishers.
References that were used in this presentation ……………

25. External links
Case Management Software Solution
Commission for Case Manager Certification
Case Management Society of America
American Case Management Association
Case Management resources
On the Case from minoritynurse.com

26. What is the most He aha te mea nui ki te Ao? important treasure on
earth?
It is people
He aha te mea nui ki te Ao?
He tangata,
he tangata,
he tangata
Glenyse
In conclusion…………….whakatauki…………

27. Roles and Functions of the Community and Public Health Nurse

28. Upon mastery of this chapter, you should be able to:
● Identify the three core public health functions basic to communityhealth nursing.
● Describe and differentiate among seven different roles of the community health nurse.
● Discuss the seven roles within the framework of public health nursing functions.
● Explain the importance of each role for influencing people’s health.
● Identify and discuss factors that affect a nurse’s selection and practice of each role.
● Describe seven settings in which community health nurses practice.
● Discuss the nature of community health nursing, and the common threads basic to its practice, woven throughout all roles and settings.
● Identify principles of sound nursing practice in the community.

29. Three primary functions of public health
The various roles and settings for practice hinge on three primary functions of public health:
assessment,
policy development,
and assurance.
They are foundational to all roles assumed by the community health nurse and are applied at three levels of service:
to individuals,
to families,
and to communities

31. Assessment An essential first function in public health
the community health nurse must gather and analyze information that will affect the health of the people to be serve:
health needs,
health risks,
environmental conditions,
political agendas,
and financial and other resources

32. Policy Development
is enhanced by the synthesis and analysis of information obtained during assessment.
At the community level, the nurse provides leadership in convening and facilitating community groups to evaluate health concerns and develop a plan to address the concerns.
Typically, the nurse recommends specific training and programs to meet identified health needs of target populations.

33. Assurance
Assurance activities—activities that make certain that services are provided—often consume most of the community health nurse’s time.
Community health nurses perform the assurance function at the community level when they
provide service to target populations,
improve quality assurance activities,
and maintain safe levels of communicable disease surveillance and outbreak control.

34. Standards for Community Nursing
Individuals should receive nursing services based on standards developed by the American Nurses Association (ANA), such as:
the Code for Nurses With Interpretive Statements (1985),
Nursing’s Social Policy Statement (1995),
Standards of Clinical Nursing Practice (2nd edition) (1998a),
The Scope and Standards of Public Health Nursing Practice (1999).

35. Clinician Role
The most familiar role of the community health nurse is that of clinician or care provider;
means that the nurse ensures that health services are provided not just to individuals and families, but also to groups and populations.
Three clinician emphases, in particular, are useful to consider here:
holism,
health promotion,
and skill expansion.

36. Holistic Practice
In community health a holistic approach means considering the broad range of interacting needs that affect the collective health of the “client” as a larger system
Holistic nursing care encompasses the comprehensive and total care of the client in all areas, such as physical, emotional, social, spiritual, and economic.

37. Health promotion
The clinician role in community health also is characterized by its focus on promoting wellness.
Examples include immunization of preschoolers, family planning programs, cholesterol screening, and prevention of behavioral problems in adolescents.
Protecting and promoting the health of vulnerable populations is an important component of the clinician role

38. Expanded Skills
With time, skills in observation, listening, communication, and counseling became integral to the clinician role as it grew to encompass an increased emphasis on psychological and sociocultural factors.
Recently, environmental and community-wide considerations, such as problems caused by:
pollution,
Violence and crime,
drug abuse,
unemployment, poverty, homelessness,
and limited funding for health programs
have created a need for stronger skills in assessing the needs of groups and populations and intervening at the community level.

39. Role of the Public Health Nurse
To: Provide input to interdisciplinary programs that monitor, anticipate and respond to health problems in population groups for all diseases or public health threats including bioterrorism
To: Evaluate health trends and risk factors of population groups to help determine priorities forming targeted interventions

40. Role of the Public Health Nurse
To:
Work with the community or specific population groups to develop targeted health promotion and disease prevention activities
To: Evaluate health care services
To: Provide health education, care, management and primary care to individuals and families who are members of vulnerable populations and high risk groups

41. Public health nurses integrate community involvement and knowledge of the entire population with the personal clinical understandings of health and illness gleaned from the experiences of individuals and families within the population.

42. The nurse working in public health should be a voice for members of the community to voice problems and desires

43. The public health nurse can apply her knowledge of strategies to choose the intervention(s) that meets the needs of a particular community, family or individual

44. The nurse is the agent who translates and applies the knowledge of health and social sciences to individuals and population groups through specific interventions, programs and advocacy

45. He or she also articulates and translates health and illness experiences of diverse, often vulnerable, individuals and families to the health planners and policy makers

46. Standards of practice have been established by the American Nurses Association

47. The Quad Council, made up of four public health nursing organizations, has established core competencies

48. These competencies reflect an agreement by the Quad Council that the public health nurse requires preparation at the baccalaureate level.

49. However, in many states nurses doing public health work are not baccalaureate graduates.

50. Even early on, the shortage of nurses affected the hiring of BSN or MSN prepared nurses. Public health departments could not compete with hospital systems.

51. The specialist level competencies require preparation at the Master’s level in community and /or public health nursing.