Collaboration for Improving Outcomes

Paper details:

SIM440 Collaboration for Improving Outcomes

Course Descriiption
This course covers current topics and trends in Nursing Case Management. This course will
cover a wide array of topics including disease navigation and demand management. The
course focuses on the nurse’s role in a collaborative team approach utilizing both acute and
community settings. The course offers a cumulative final project whereby the student
chooses his or her patient population and builds the project on that specific patient/disease
type.
Course Competencies
Upon completion of this course, students will be able to:
1. Assess the roles of the nurse case manager in the contemporary health care
structure.
2. Develop a holistic case management plan for a specified disease or population that
incorporates the role of insurance, health care finance, and utilization of community
resources.
3. Examine the role of case management in end-of-life care including ethical and legal
issues.
4. Coordinate the care of individuals across the lifespan utilizing principles and
knowledge of interdisciplinary models of care delivery and case management.
Additional Instructions:
● All submissions should have a title page and reference page.
● Utilize a minimum of two scholarly resources.
● Adhere to grammar, spelling, and punctuation criteria.
● Adhere to APA compliance guidelines.
● Adhere to the chosen Submission Option for Delivery of Activity guidelines.
Activity 1 (4 -page paper. Include title and reference pages)
Case Management Implementation Plan
Create a plan to implement case management at your workplace. What is your
recommended plan for the use of case managers in your organization for patients with your
chosen chronic illness? Identify people within your organization who are stakeholders or
would support your plan. Whose support do you need to get your plan implemented? Identify
your goals – what do you hope to accomplish with your case management plan?
Often, starting with our goals helps – it’s a backward design. As we think about a case
management plan we are proposing for our workplace, what do we want to accomplish?
Remember – goals should be measurable. For example, if the chosen chronic disease is
diabetes, one goal may be:
● Clients will have decreased incidences of hyperglycemia requiring hospitalization
Once we determine what we want to accomplish, we can begin to construct our plan to
achieve the goal. To achieve this goal, our plan may include providing education in a manner
the client can understand (being sensitive to cultural needs), access to phone support, or
inputting glucose readings into their electronic health record for documentation the case
manager can evaluate and use to reach out to the client.
To put this plan in action, whose support would we need? Primary Care Physicians,
Utilization Review personnel, and the Chief Financial Officer would all have an interest in
optimizing patient health and reducing costs.
Reading and Resources
Read Ferrier, G. D., & Trivitt, J. S. (2013). Incorporating quality into the measurement of
hospital efficiency: A double DEA approach. Journal of Productivity Analysis, 40(3), 337-355.
https://search.proquest.com/docview/1448800469?accountid=169658
Search the site for US Department of Health and Human Services “Hospital Compare” and
use the interactive database to compare and contrast health plans, hospitals, etc. How might
you use this site with patients as a case manager?
Activity 2 (4 -page paper. Include title and reference pages)
Chronic Disease Management
Choose one of the following chronic diseases to address in this component:
● Hypertension
● Chronic Obstructive Pulmonary Disease
● Diabetes Mellitus type 2
● Childhood Asthma
Complete the following:
● Detail the population including who the members are, contributing causes, past
medical history, family/genetic components.
● Evaluate the population including size, seriousness of disease, special needs, etc.
● Assess the need for formal case management.
● Argue the potential benefits to implementing a case management model including
economics, quality of life/care, social disruption, etc.
● Analyze why nursing should be a part of this plan. What can they bring to the table?
● Identify other team members who should be included on a case management team.
Why should they be on this team and what is their role?
Reading and Resources
Chapter 2 pages 44-47 in Fundamentals of Case Management Practice
De Regge, M., Pourcq, K. D., Meijboom, B., Trybou, J., Mortier, E., & Eeckloo, K. (2017). The role
of hospitals in bridging the care continuum: A systematic review of coordination of care and
follow-up for adults with chronic conditions. BMC Health Services Research, 17
Davis, M. M., Devoe, M., Kansagara, D., Nicolaidis, C., & Englander, H. (2012). “Did I do as best
as the system would let me?” healthcare professional views on hospital to home care
transitions. Journal of General Internal Medicine, 27(12), 1649-56.
Activity 3 (4 -page paper. Include title and reference pages)
Continuum of Care
Explain how the concept continuum of care is used in case management and within your
organization. What new services/programs are your organization currently evaluating or
performing that are assisting patients to reach their health goals? How do these
services/programs impact the bottom line of the organization?
Quality indicators, such as accessibility, appropriateness, continuity, effectiveness, efficacy,
efficiency, timeliness, patient perspective issues, and safety, can influence quality of care.
Choose one indicator and discuss its influence on care inventory environments, including
local, state, national, and global. Discuss the practice of linking hospital reimbursement to
performance outcomes.
Reading & Resources
● Chapter 2 pages 44-47 in Fundamentals of Case Management Practice
● De Regge, M., Pourcq, K. D., Meijboom, B., Trybou, J., Mortier, E., & Eeckloo, K. (2017).
The role of hospitals in bridging the care continuum: A systematic review of
coordination of care and follow-up for adults with chronic conditions. BMC Health
Services Research, 17
● Davis, M. M., Devoe, M., Kansagara, D., Nicolaidis, C., & Englander, H. (2012). “Did I do
as best as the system would let me?” healthcare professional views on hospital to
home care transitions. Journal of General Internal Medicine, 27(12), 1649-56.
● Asgar, A. H., Ravaghi, H., Kringos, D. S., Ogbu, U. C., Fischer, C., Azami, S. R., & Klazinga,
N. S. (2014). Using quality measures for quality improvement: The perspective of
hospital staff. PLoS One, 9(1)
● Buerhaus, P. I., DesRoches, C., Applebaum, S., Hess, R., Norman, L. D., & Donelan, K.
(2012). Are nurses ready for health care reform? A decade of survey research. Nursing
Economics, 30(6), 318-29, quiz 330.
● Elwood, T. W., DrP.H. (2013). Health reform in the context of entelechy. Journal of
Allied Health, 42(3), 127-34.
● Feemster, L. C., & Au, D. H. (2014). Penalizing hospitals for chronic obstructive
pulmonary disease readmissions. American Journal of Respiratory and Critical Care
Medicine, 189(6), 634-9.
● Review American Association of Managed Care Nurses to explore information related
to finance and payment structuring.
Activity 4 (8pages form – Utilize discharge plan document template)
Discharge Plan
For the discharge plan, you will create a fictitious patient with your chosen chronic illness
and use this Discharge Plan document to create a discharge plan for that patient. You are to
complete all sections of the discharge plan: assessment, diagnosis/plan, education needs,
financial worksheet, and the reflection and conclusion. You need to be as detailed as
possible in filling out all the boxes. The reflection and conclusion section allows you to
summarize the patient’s plan of care based on all proceeding information and to make
recommendations for the plan of care for the patient. Reflect on what you learned in this
activity. What do you think about using this discharge plan, did it help you to consider areas
you might not have previously included in a discharge plan?
You can type right into the document, save it, and submit for grading.
Reading and Resources
Chapter 16 pages 297-316, Chapter 23 pages 395-404, Chapter 20 pages 367-375, Chapter 26
pages 439-447 in Fundamentals of Case Management Practice.
Review clinical guidelines of the AHRQ
*Activity must be submitted per the Discharge Plan document
Activity 5 (4 -page paper. Include title and reference pages)
Evidence-Based Practice and Case Management
Using your chosen chronic illness from the list below,
● Hypertension
● Chronic Obstructive Pulmonary Disease
● Diabetes Mellitus type 2
● Childhood Asthma
you will explore the use of evidence-based practice and how it is incorporated into case
management patient care guidelines and pathways.
● Identify and discuss current best practices. Address the importance of basing case
management on current evidence.
● Identify and evaluate published guidelines.
● Identify and discuss clinical pathways and how they relate to your chosen illness.
Reading and Resources
● Pizzi, Michael A,PhD., O.T.R./L. (2014). Promoting health, wellness, and quality of life at
the end of life: Hospice interdisciplinary perspectives on creating a good death.
Journal of Allied Health, 43(4), 212-20.
● Annicka G M van der,Plas, Vissers, K. C., Francke, A. L., Donker, G. A., Jansen, W. J. J.,
Deliens, L., & Onwuteaka-Philipsen, B. (2015). Involvement of a case manager in
palliative care reduces hospitalisations at the end of life in cancer patients; A
mortality follow-back study in primary care. PLoS One, 10(7)
● Meyer, Star,R.N., B.S.N. (2012). Care management role in end-of-life discussions. Care
Management Journals, 13(4), 180-3.
● Review the National Committee for Quality Assurance certification criteria.
Activity 6 (4 -page paper. Include title and reference pages)
Family Support Assessment
Case management is useful in a variety of settings. You will be using the nursing process to
conduct an in-home assessment in Sentinel City® to develop a plan of care for a family. The
process of collecting, analyzing, and synthesizing data from a variety of sources can help the
nurse to gain an understanding of family strengths, values, and needs related to physical and
social determinants of health to promote the health and well-being of the family unit.
1. Include a properly formatted community health nursing diagnosis that addresses
either preschool-age children, single mothers, or pregnant women.
2. Increased risk of (disability, disease, etc.) among (community or population) related to
(disability, disease, etc.) as demonstrated in or by (health status indicator, or
etiological/causal statement).
○ Example: Increased risk of obesity among school-age children related to lack
of safe outdoor play areas for children as demonstrated by elevated BMI rates.
Reading and Resources
Chapter 16 pages 297-316, Chapter 23 pages 395-404, Chapter 20 pages 367-375, Chapter 26
pages 439-447 in Fundamentals of Case Management Practice.
Review clinical guidelines of the AHRQ
Activity 7 (4 -page paper. Include title and reference pages)
Home Safety Assessment
It is important to identify health issues or concerns that may impact an individual or family in
any setting. This identification can help the nurse to address health promotion and disease
prevention.
To complete this activity, you must complete the Family Support Assessment activity. Click
on Enter Sentinel City®. Once in the city, click on the map to locate the apartment dwelling in
Nightingale Square. Approach the door next to the laundromat and enter the apartment.
Here you will complete the Home Safety Assessment by noting any health, safety, and
environmental hazards in the apartment. Note as many of the hazards that you observe.
Select and prioritize the top two hazards for health, safety, and environmental areas for a
total of six hazards that the healthcare professional should address first:
1. #1 = most serious hazard-life threatening
2. #2 = second most important-potential to affect the most people or cause long-term
injury
Try to avoid prioritizing the same hazard in multiple categories. Provide an evidence-based
rationale and a recommendation for addressing the top two hazards in each category. Click
the “Family Support Assessment” tab at the top of the screen and review the information on
the form.
Reading and Resources
Chapter 16 pages 297-316, Chapter 23 pages 395-404, Chapter 20 pages 367-375, Chapter 26
pages 439-447 in Fundamentals of Case Management Practice.
Review clinical guidelines of the AHRQ
Activity 8 (4 -page paper. Include title and reference pages)
Regulatory Environment
Explain how healthcare exchanges change the concept of outpatient treatment. Many clinical
information systems now embed practice guidelines and clinical pathways into their
electronic medical record systems. Discuss some of the advantages and disadvantages of
this. Describe demand management and how it can increase consumer involvement in care.
Compare and contrast disease management and case management.
Reading and Resources
● Ferrier, G. D., & Trivitt, J. S. (2013). Incorporating quality into the measurement of
hospital efficiency: A double DEA approach. Journal of Productivity Analysis, 40(3),
337-355. https://search.proquest.com/docview/1448800469?accountid=169658
● Search the site for US Department of Health and Human Services “Hospital Compare”
and use the interactive database to compare and contrast health plans, hospitals, etc.
How might you use this site with patients as a case manager?
● Chapter 16 pages 297-316, Chapter 23 pages 395-404, Chapter 20 pages 367-375,
Chapter 26 pages 439-447 in Fundamentals of Case Management Practice.
● Review clinical guidelines of the AHRQ
● Pizzi, Michael A,PhD., O.T.R./L. (2014). Promoting health, wellness, and quality of life at
the end of life: Hospice interdisciplinary perspectives on creating a good death.
Journal of Allied Health, 43(4), 212-20.
● Annicka G M van der,Plas, Vissers, K. C., Francke, A. L., Donker, G. A., Jansen, W. J. J.,
Deliens, L., & Onwuteaka-Philipsen, B. (2015). Involvement of a case manager in
palliative care reduces hospitalisations at the end of life in cancer patients; A
mortality follow-back study in primary care. PLoS One, 10(7)
● Meyer, Star,R.N., B.S.N. (2012). Care management role in end-of-life discussions. Care
Management Journals, 13(4), 180-3.
● Review the National Committee for Quality Assurance certification criteria.
Activity 9 (4 -page paper. Include title and reference pages)
Role and Function
Describe the roles and functions of the nurse case manager in (1) acute care, (2) home care,
and (3) primary care settings.
Often the case manager is a social worker rather than a nurse. What skills would a nurse
need to have to better prepare to do a community health plan for a patient? Why are these
skills important?
What are some of the approaches case managers use to promote the highest quality of care
with careful use of resources? Think globally…how can palliative care and hospice services
assist this strategy.
Reading and Resources
● Chapter 1 in Fundamentals of Case Management Practice
● Case Management Society of America
● Pizzi, Michael A,PhD., O.T.R./L. (2014). Promoting health, wellness, and quality of life at
the end of life: Hospice interdisciplinary perspectives on creating a good death.
Journal of Allied Health, 43(4), 212-20.
● Annicka G M van der,Plas, Vissers, K. C., Francke, A. L., Donker, G. A., Jansen, W. J. J.,
Deliens, L., & Onwuteaka-Philipsen, B. (2015). Involvement of a case manager in
palliative care reduces hospitalisations at the end of life in cancer patients; A
mortality follow-back study in primary care. PLoS One, 10(7)
● Meyer, Star,R.N., B.S.N. (2012). Care management role in end-of-life discussions. Care
Management Journals, 13(4), 180-3.
● Review the National Committee for Quality Assurance certification criteria

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