Before discharging a stroke recovery client from an acute care facility, the nursing case manager organizes a meeting involving the nursing staff, client, client's family, physical therapist, and home health nurse. The main objective of this meeting is most likely to:
A. Assess the effectiveness of the client's stay in the hospital.
The coordination and facilitation of care are crucial responsibilities that case managers and social workers often play, although they may not always receive the recognition they deserve.
In particular, the coordination of care is an essential part of the role that case managers and social workers fulfill.
By effectively coordinating care, these professionals are able to ensure that patients receive the necessary resources and support they need for optimal healthcare outcomes.
Not all patients require in-home case managers for successful healthcare management. However, older individuals, those with chronic illnesses, or those with limited support may benefit from a visit from a case manager. The field of case management is a promising opportunity for nurses to enhance the care they provide to their patients.
Home health care nurses commonly serve as case managers for their patients.
There are nurse case managers who specialize in geriatrics and work specifically with elderly patients and their caregivers.
A nurse case manager's responsibilities can include reviewing the patient's medical history and records to ensure that they are receiving appropriate care.
Respite care is an invaluable hospice benefit that case managers can use to support families in critical need. Through their education and training, case managers can assess a family's situation and determine if respite care is necessary. They can also coordinate assessments with behavioral health professionals when needed.
Considering hospice and respite care is an important aspect of case management. Case managers can provide valuable support to families by understanding when respite care is needed and making the necessary arrangements for it.
Each hospice provider designs a personalized plan of care (POC) for every patient. The POC is developed by an Interdisciplinary Group (IDG) and supervised by a Registered Nurse (RN) coordinator.
All hospice care and services provided to patients and their families are based on an individualized written POC. This ensures that each patient receives the necessary and appropriate care and support.
Coordination is a key aspect of the case manager's role and involves three main elements. First, there are managerial responsibilities that pertain to overseeing the patient's journey throughout their episode of care. Second, there is the coordination of a multidisciplinary team to ensure effective collaboration. And finally, there are clinical responsibilities involved in implementing a plan of intervention.
The role of a case manager requires certain qualities and skills. These include strong managerial abilities, the ability to bring together and lead a diverse team, and the clinical expertise required to implement interventions effectively. Additionally, effective communication, problem-solving, and decision-making are essential in fulfilling the responsibilities of a case manager.
Patients can receive hospice care either in their own homes or in assisted living facilities. In a survey, respondents were asked to rate their family member's hospice care on a scale of 0 to 10, with 0 being the lowest quality and 10 being the highest.
The measure is derived from the analysis of Medicare hospice claims records and assesses the percentage of patients in hospice care who have received in-person visits from a registered nurse or medical social worker on two or more of the final three days of their life.
This measure is part of the Hospice Quality Reporting Program (HQRP) administered by the Centers for Medicare and Medicaid Services.