L7 Case management and symptoms management

Define what is case management

An integrated collaborative process of assessment, planning, facilitation, and advocacy of options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes

A way of helping people identify the areas where they need help and connecting them to the personal and community resources that will help them

List the client-centered goals of case management (4)

• Promote optimal health

• Ensure effective coordination of care

• Provide clients with continuity of care

• Improve quality of life

List the system-centered goals of case management (3)

• Manage resource allocation

• Alleviate fragmentation of care

• Emphasizes service delivery in a cost-effective way

What are the 5 essential elements of case management ?

1. An accurate assessment and ongoing evaluation of client needs

2. The ability to link clients to resources appropriate to their needs

3. The power to ensure that appropriate and needed services are actually delivered

4. The capacity to see that services are utilized

5. A commitment to evaluating the impacts and outcomes of interventions

How to effectively teach clients ?

TEACH mnemonic:

• Tune in: listen before you start teaching, client’s needs should direct the content

• Edit information: teach necessary information first, be specific

• Act on each teaching moment: teach whenever possible, develop a good relationship

• Clarify often: make sure your assumptions are correct, seek feedback

• Honor the client as a partner: build on the client’s experience, share responsibility with the client

Describe the step 1 of case management

Defining the problem

• Start with an information-gathering procedure

• To find out everything about a client and his/her life that could be relevant to problem-solving

• Use of standard form to guide information-gathering

(ie. assessment, referral & history form ; CBNS. system: initial assessment, Barthel index, wound, Morse scale, Braden scale, social support, homer care record…)

• Barthel index: measures a person's level of independence in basic activities of daily living (ADL)

• Braden scale: patient's risk of developing pressure ulcers

• Morse scale: Fall risk

Describe the step 2 of case management

Determining the severity of the problem

• Aware of a series of possible client problems

• Determine the severity of a problem, to direct indication of how immediately it needs to be addressed

• Take into consideration of clients, respect for their sense of themselves

(e.g. pain on operation site, fall risk, cultural belief, drug compliance, worried about daughter’s away, risk of dislocation…)

Describe the step 3 of case management

Developing hypotheses concerning why client problems are occurring

Assessment

• To understand how the interplay of forces from micro to macro that affect the client

  • Micro: e.g. what role does the family play? What attempts have the client and family made to resolve the problem?

    • e.g. Does Mary’s daughter make any arrangement for Mary during her business trip ?

  • Macro: e.g. what are the governmental policies and regulations that govern support for the clients

    • e.g. Could the client be referred to respite service OAH under SWD for a short-term stay ?

• Provide direction of service interventions

(Hypothesis e.g. Walking triggered painful sensation, unsteady gait further triggered unwillingness / afraid of walking, cultural belief affects drug compliance)

Describe the step 4 of case management

Establishing goals

• Include both long-term and short-term goals and have measurable goals for different areas worked into a timeline.

• Consider the client’s cultural background, values, and interests in order to ensure that the plan is appropriate for that individual.

(e.g. Physically, Psychosocially, Culturally)

Describe the step 5 of case management

Developing and Implementing A service Intervention Plan

• Work with the client: crisis intervention, focused short-term casework, making referrals, advocacy for services, coordinating service delivery, or tracking service utilization and goal attainment

• Work at the community intervention level to pave the way for support services for your clients, enhance existing resources at agencies, or develop resources where none exist

(e.g. Physically: take medication as prescribed, Psychosocially: referal to OAH for short-term until daughter’s return, Culturally: advise Mary to take prescribed drug as scheduled and take CMed at least 2 hours after drug taking)

Describe the step 6 of case management

Evaluation

• To determine the degree of goal-attainment

• The evaluation questions are dictated by goals

  • e.g. Did the client adhere to the medication regimen? If yes, to what extent? If no, why?

  • If clients consistently fail to attain goals, may not represent the failure of case manager. Some client’s problems are very resistant to measurable changes in short term

  • Heavy caseloads may be causing the failure to meet the goals

Describe the step 7 of case management

Termination

Terminate if:

• Clients have reached their goals

• Clients have satisfactorily demonstrated they can self- manage their own movement toward goals

• Clients successfully working with social service agencies, community support systems, or other referral sources

Ultimate goal of case management:

• To teach clients to be able to successfully identify, assess, and solve their problems using their own abilities

What is the overall aims of virtual ward ?

• To reduce avoidable admission

• To improve care

A virtual ward, also known as "hospital at home," allows patients to receive acute, hospital-level care, monitoring, and treatment in their own homes rather than a hospital bed. It utilizes technology (apps, wearables, monitoring devices) for remote supervision by a multidisciplinary team, reducing hospital admissions and freeing up physical beds.

Who is the target of virtual ward

• Patients living with the family or caregiver at home

• High readmission risk (HARRPE ≥0.4)

• Moderate to end stage chronic illnesses

• Complex care and/or end-of-life care

What is the management purpose for virtual ward ? (3)

1. Providing a timely assessment and intensive support to patients experiencing an acute exacerbation of their condition and coordinating a range of services to reduce admission to hospital

2. Facilitating earlier discharge of patients with long term condition thereby reducing length of stay

3. Identifying a single point of contact for care and advice for patients, carers and other health professionals

what are the characteristics of virtual ward ? (6)

• Case management approach

• Multidisciplinary team care

• Extended service hours

• Protocol-driven investigations

• Substitutive hospital-at-home interventions

• Regular ward round and case conference

(high satisfaction in cost-effectiveness as well)

Explain the symptom management theory

SMT states that symptom management is a multidimensional dynamic process encompassing three core concepts: symptom experience, symptom management strategies, and outcomes.

What are the common symptoms among community-dwelling clients ? (6)

• Weight loss

• Dizziness

• Fever

• Chest pain

• Dyspnoea

• Ankle swelling

Suggest the management for weight loss

• Identify possible causes, provide psychological support & nutritional counselling, provide suitable assistive devices, maintain oral hygiene

  • e.g. overactive thyroid, loss of appetite, celiac disease, addison’s disease, heart condition, DM, rheumatoid arthritis, cancer, depression pancreatitis, parasite…

• Refer to urgent management if getting deteriorated

Suggest the management for dizziness

• Keep bed rest with eyes closed, monitor vital signs, withhold anti -hypertensive drugs if BP on low side

• Refer to emergency care if experience is new, with severe dizziness along with other symptoms such as severe headache, chest pain...

Suggest the management for fever

• Encourage fluid intake, promote surface cooling, administer anti-pyretic,

• Refer to emergency care if no response to symptomatic relief management, with deteriorating vital signs, increasing drowsiness, presence of convulsion...

Suggest the management for chest pain

• Keep resting, TNG for heart origin, antacid for GI origin, local analgesics for musculoskeletal origin

• PQRST assessment

• Refer to urgent treatment if symptoms persisted, which may indicate acute condition

Suggest the management for dyspnoea

• Prop up, keep bed resting, rule out suffocation, assess airway, provide psychological support, purse-lip breathing for COPD exacerbation, fluid restriction for CHF exacerbation

• Refer to urgent treatment if severe dyspnoea, associated with retrosternal chest pain

Suggest the management for ankle/leg swelling

• vital signs monitoring, administer prescribed diuretics, educate drug compliance, elevate limbs, restrict fluid and salt intake, educate foot care, prevent fall, check urine output and urine albumin, give analgesic and dressing for tissue injury

• Refer to emergency treatment if severe SOB with wheezing, severe pain after trauma, no urine output for 12 hours, acute onset of severe unilateral swelling