There or discharge plan. After assessing the


There are 6 steps of case management and the first step to
identify the patient. The case manager will identify clients who will benefit from
the case management service based on certain specific criteria. The will be a
screening or an assessment tool will be used to assist in identifying the
client. Important key information may include health services utilization, past
and current health condition, socioeconomic and financial status, health
insurance coverage, home environment, prior services,
physical/emotional/cognitive functioning, psychosocial network and support
system, and self-care ability. One type of screening tool would be the Coleman’s
model focuses on the four pillars which are medication self-management, use of
a dynamic patient-centred record, primary care and specialist follow-up and knowledge
of red flags.

Next is the assessment which is to identify the actual and
potential problems that can arise. This is to know the needs of the patient so
that to categorise them in either transitional care or discharge plan. After assessing
the patient, the case manager will set goals and plan necessary intervention and
engage on the appropriate resources. The two main parts of this is to identify
the client’s key problems that needs to be addressed, as well as individual
needs and interests. And, developing a comprehensive case management plan of
care that addresses these problems and needs. One example is when the case manager
is conducting a home visit. The case manager must take note of the living
condition of the patient adherence to certain treatments. The case manager will
then conduct an assessment for example, for patients with chronic illness must know
their risks and the signs and symptoms. They also must remind the clients about
upcoming appointments. There are 3 types of geriatric assessment which are cognitive
and affective assessment, social assessment and functional assessment.  This type of assessment is for case managers
to obtain information about functional performance about older adults.

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Planning is the next step which is to establish goals and the
needs of the patient as well as the types of services needed will be the top
priority so that to be able to achieve the desired outcome. Planning also helps
to reduce risks and it also helps the patient to have a smooth journey
throughout. Case managers may consider the services in the community that can be
beneficial for the patient. The case management plan of care identifies
outcomes that are achievable within an appropriate time frame and that apply
evidenced-based standards and care guidelines. Planning is completed after
getting authorization for the health and human services to be rendered has been
given and after the services and resources needed have been identified.

Implementation is next whereby the case manager will
coordinate the activities for the patient and will reassess the patient frequently
so that to identify if there is any modification needed. For example, if the
patient is an elderly and is living alone, there might be a high risk of
injuries. Hence, the case manager will arrange home occupational therapy
assessment get referral from social workers and engage for financial
assistance. The case manager asks about the client’s comfort with self-care, intake
of medications, availability of post-transition services (e.g., visiting
services), and if there are any issues. The case manager gets feedback
regarding the client’s experience and satisfaction with services rendered. The
case manager also follows up on issues and problems identified during the
post-transition communication and seeks resolution on these issues. Also, the case
manager reports the feedback gathered during the communication to important
stakeholders such as payors and providers of care. Depending on the issue or
concern identified, the case manager may engage other healthcare professionals.

The case manager will then evaluate the patient care
activities and examines the patient condition and the status of their goal. During
this phase, the case manager generates outcome reports such as case summary,
cost/billing, satisfaction and outcomes of the patient, cost-benefit analysis,
and return on investment. The case manager conveys the findings to important
stakeholders such as government agencies, client, payor, providers of care,
employers, interdisciplinary team members, risk management staff, quality
improvement team members, and others.

Lastly, when the patient has achieved the desired goal based
on their choice or from their family members, the case manager is no longer
needed to provide services and hence the termination of the case management