Case Management Plans, Clinical Pathways, and Protocols

Mary Jane McKendry

INTRODUCTION

A. As the roles of case managers expand and transform in response to changes in the health care marketplace, many case managers find that the traditional goals of case management (CM) seem incongruent with current responsibilities. Often case managers feel conflicted as they try to deliver patient-centered care, while at the same time attempting to reduce costs and control resource utilization.

B. In reality, case managers are trying to meet the goals of many different customers at the same time. For example, keeping care patient-centered is necessary, but so is reducing variation, duplication, and fragmentation of care. Similarly, it is imperative that case managers help patients access appropriate resources to maintain their individual optimal level of wellness; on the other hand, utilization and costs must be addressed and controlled. Helping patients access appropriate resources at the right time results in cost savings and appropriate utilization of resources.

C. It may be possible to achieve balance in both the patient-centered and system-centered goals of CM. In doing this, we start to identify the complexity of the case manager’s job and to understand that case managers need a care road map to guide the successful resolution of any identified needs or issues. Consider that perhaps case managers need to have not only clinical skills but also business skills. In this context, system-centered goals may address data gathering and analysis, reducing clinical variation, meeting expectations for timeframes, and addressing available resources, while patient-centered goals may address accessing appropriate care in a timely manner, providing education and tools to ensure patient empowerment, and encouraging patient self-management (Padgett, 1998).

D. Today, the consumers of CM services require well-defined and well-managed plans of care that effectively and efficiently address resource utilization, while at the same time ensure the access to, and quality of, care. By utilizing collaborative approaches for CM care planning, case managers can create a “dashboard” to assist them in meeting the goals and responsibilities of CM; the needs of the patient; and the needs of other CM customers such as employers, health plans, health care facilities, etc. A dashboard is an internal management reporting system for a department or program (in this instance, CM) that provides high-level executive summary reports of the program.

E. Through the use of dashboard reports, users will be able to see if, how, and where the CM company or department is progressing (or not progressing) in its improvement efforts.

F. This chapter on CM plans provides an overview of CM plan design, reviews tools available to assist in evidence-based CM plan development, and discusses strategies for developing comprehensive, multidisciplinary plans of care.

KEY DEFINITIONS

A. Algorithm—A binary decision tree that guides step-by-step assessments and interventions. Algorithms are generally most useful for high-risk groups as they are known for their specificity (very specific) and generally do not allow for provider/patient flexibility. Often utilized to manage a specific process, control care practices, or address an individual problem. Algorithms may incorporate research methodology to measure cause and effect (Wojner, 2001).

B. Case management care plan (CM plan)—“A comprehensive plan that includes a statement of problems/needs determined upon assessment; strategies to address the problems/needs; and measurable goals to demonstrate resolution based upon the problem/need, the time frame, the resources available, and the desires/motivation of the client/family” (CMSA, 2002, p. 21).

C. Clinical pathway—A structured, multidisciplinary CM plan designed to support the implementation of specific clinical guidelines and protocols. Clinical pathways are computational maps or algorithms that guide the healthcare team, especially the non-physician care team members, on the usual treatment patterns related to common diagnoses, conditions, and/or procedures.

Clinical pathways are designed to support clinical management, clinical and nonclinical resource management, clinical audit, and financial management.
Clinical pathways promote quality care and decrease costs by standardizing treatment methods within clinical processes, while at the same time endeavoring to improve the continuity and coordination of care across different disciplines.
Clinical pathways also are known by many synonyms including integrated care paths, multidisciplinary pathways of care, care maps, critical pathways, collaborative pathways, or care paths (McKendry, 2004; Open Clinical, 2006).

D. Evidence-based criteria/guidelines—Evidence-based criteria are based on the premise of evidence-based medicine (EBM) and are systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for specific clinical circumstances. (Field and Lohr, 1990).

Evidence-based guidelines are generally designed for use by physicians, nurse practitioners, and physician assistants. They help promote quality of care by monitoring performance and identifying improvement opportunities.
Guidelines commonly apply to a general health condition. To be defensible, guideline development must be able to demonstrate:
- A development process that is open, documented, and reproducible;
- That the resultant product can be of use to both clinicians and patients;
- That the concept of appropriateness of services is well reflected in the guideline; and
- That the guideline relates specifically to clearly defined clinical issues (“Proof and Policy,” 2001).

E. Protocol—Guidelines designed to address specific therapeutic interventions for a given clinical problem. Protocols are less specific than algorithms and do allow for minimal provider flexibility via treatment options. They are multifaceted and therefore can be used to drive practice for more than one discipline. Like algorithms, they may incorporate research methodology to measure cause and effect (Wojner, 2001).

CM CARE PLANNING AND PLANS OF CARE

A. What is CM care planning if not an essential part of health care? Yet it is often misunderstood or even regarded as a waste of time and effort.

B. Historically, CM was often viewed as a social worker function. In the late 1980s, CM care planning became more of a nursing responsibility. Conceptualizing CM as either social work or nursing is inaccurate; doing so does not effectively involve all members of an interdisciplinary care team. Case managers understand that CM care planning must include all disciplines/members of the health care team involved in the care of a patient. According to the Case Management Society of America (CMSA) CM care planning is a case manager’s primary function.

C. Fundamental components for appropriate CM care planning can be found in CMSA’s standards of practice and include:

The use of evidence-based criteria whenever possible;
A fiscally responsible CM plan that enhances quality, access, and cost outcomes;
Direct communication with the patient and their family/support structure;
Direct and/or indirect communication with members of the health care team, including the patient’s physician(s);
Education for the patient and their family/support structure so that informed decision making can occur;
Contingency planning to anticipate health and service complications;
Ongoing assessment and re-evaluation of the patient’s health and progress; and
A CM plan that is dynamic and adaptable to changes occurring both over time and through various settings (CMSA, 2002).

D. CM care planning should be action oriented and time specific. The end result of CM care planning is a patient-centered CM plan. Consequently, one of the most significant responsibilities for a case manager is the development of a CM plan. The CM plan must be able to:

Be individualized yet focus on multidisciplinary care requirements;
Work for the patient and their family/support structure, physicians, and other members of the health care team;
Be consistent with an individual’s needs, preferences, and values; and
Demonstrate that the patient understands and has agreed with the CM plan.

E. The effective CM plan is a specific document that delineates:

Individual care needs (both diagnostic and therapeutic),
Actions required (actions by the CM and/or by the patient),
Short- and long-term goals and timeframes for attainment, and
Anticipated outcomes.

CM PLAN DEVELOPMENT—PATIENT ASSESSMENT

A. Developing a patient-specific process should follow a logical progression.

B. The first step in CM care planning is an accurate and thorough needs assessment. The assessment begins with an accurate determination of the patient’s current status and includes an evaluation of the patient’s:

Physical needs
Acuity, comorbidity, polypharmacy
Psychological needs
Social, environmental, and cultural needs
Care coordination requirements
Potential resource consumption
Support structure
Quality indicators
Health plan benefit design
Evaluation/assessment of potential or present safety issues
Community resources

C. Once a current patient status is determined, the case manager must ask three fundamental questions:

What are we trying to accomplish? What are the goals for improvement and are they measurable?
How do we know that a planned approach (intervention) will result in an improvement/goal attainment?
What measurable approach (intervention) can be made that will result in an improvement? Who will do what, for what purpose, and at what frequency?

D. Answering these questions help case managers formulate CM plans that are individualized; contain reasonable goals; and have achievable, measurable, and time-bound outcomes.

E. Let’s look at these questions in more detail to understand how they can help formulate a CM plan.

What are we trying to accomplish?
- This question may drive one or multiple goals. Additionally, the CM plan’s priorities may begin to emerge and primary and secondary goals are more easily defined. Examples of goals that may be identified include:
  - Patient education related to specific aspects of care/self-management, disease condition, medications, etc.
  - Patient empowerment
  - Patient self-management of activities of daily living (ADLs)
  - Respite care
  - Transportation to/from required medical services such as dialysis or physical therapy
  - Glycemic control for patients with diabetes
  - Reduction in emergency room utilization
  - Appropriate family/social support structure in place
  - Access to required nutritional, medical, pharmaceutical, or other needs
  - Successful return to work
- How are the above goals measured? What about the timeframes for accomplishment? Are they short-term or long-term goals? By answering these questions we obtain useful patient-centered information that allows us to write specific statements of expected goals and determine if goals are immediate, short-term, or long-range. It is important to realize that goals contain functional and measurable information such as:
  - A general description of purpose—stating the aim clearly
  - The specific focus—performed by whom, taking place where, requiring what
  - Numerical targets—timeframes for completion that are based on measurable data
- Goals should be considered targets of achievement that are specific, measurable, attainable, relevant, and time bound.
- However, since patients cannot or do not always conform to plans of care, it is essential to remember that goals must be flexible enough to be modifiable.
How do we know that a planned approach (intervention) will result in an improvement?
- This question guides the formulation of action items, which are more commonly known as interventions (e.g., CM activities), as well as the identification of problems and the formulation of problem lists.
- Basically, this question is asking the case manager to determine what interventions will actually result in improvements or in meeting the goal(s) defined. In other words, will the interventions planned actually positively affect the patient’s overall well-being?
- Once problems are determined and interventions are decided upon, the following additional questions should be asked of each problem recognized and intervention established:
  - Will this problem get better?
  - Can we make this problem get better by the intervention(s) decided on?
  - If a problem is not likely to improve or resolve, will the planned intervention(s) reduce the risk of complications or prevent the problem from getting worse?
  - If a problem is not likely to improve and, in fact, deterioration is inevitable, can the planned intervention(s) provide for optimal quality of life, comfort, and dignity for the patient? (Sox, 2006)
  - Is each defined intervention both measurable and realistic?
- Interventions may include components of physician/health care provider orders, facility protocols, best-practices standards, or accepted critical pathways.
- However, all CM plans of care should have interventions that reflect tasks that case managers can actually accomplish and should demonstrate the value of CM involvement. For example, if a physician orders nutritional supplements, the CM interventions would be focused on patient education, strategies for obtaining the nutritional supplements ordered, methods to determine that the patient receives and utilizes the nutritional supplements, and so on.
What measurable approach (intervention) can be made that will result in an improvement?

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