CMSA Today - Issue 5, 2011 - (Page 8)

Fragmented Care Case Managers are Critical to Decreasing FRAGMENTED CARE septic patient. Where is the collaboration among the providers to ensure the clinical pathway is appropriate? Many of us, as case managers, can probably think of multiple examples in which a little collaboration and communication could have avoided an unfavorable patient-outcome. In practice, the implementation of a regular interdisciplinary team meeting provides an opportunity to discuss plans of care, address barriers in care, and remove silos among practitioners. managers can contribute toward the goal of preventing miscommunication and care-fragmentation. Communication is the key. Communication starts with identifying the “thrust of care.” Teams may be sidetracked by losing focus on why the patient was originally admitted. The basic premise of the case management profession lies within our ability to communicate, analyze resources, plan, implement, and advocate. Case managers are responsible for ensuring a global perspective is applied to each patient’s plan of care. The interdisciplinary team meeting should be facilitated by case management. The meeting should begin with identifying the patient data and thrust of care. Members of the interdisciplinary team should discuss the current state of the care plan and the anticipated goals in relation to the thrust of care. Involvement of the attending physician in the interdisciplinary team meeting is critical. They are able to provide information to assist the team in their collaborative effort toward optimal patient outcomes. BY JOSE ALEJANDRO, RN-BC, MSN, MBA, CCM, FACHE and BETTY THOMAS, LCSW, Ph.D. CANDIDATE F ragmented care is a dilemma often witnessed throughout the health care continuum. While clinical care is multidisciplinary, it is also at risk at being conducted within silos wherein providers focus solely on their provision and not on the collective effort of the clinical team. Take for example, a wean attempt without taking into consideration a ROLE OF CASE MANAGEMENT WITHIN THE INTERDISCIPLINARY TEAM MEETING Case managers are privy to information regarding their patient from a variety of sources, including the family, nurses, physicians, allied health, and of course, the patient. Armed with this information, case COLLABORATION LEADS TO QUALITY CARE Mismanaged utilization of resources is often seen when there is a lack of collaboration. For example, a patient who enters the Emergency Department receives “standard” lab work. The patient may be transferred to an inpatient unit and orders are written for identical labs without clinical justification simply because it may be part of protocol. Another example is a diagnostic test done at one level of care and then subsequently performed at a different 8 CMSA TODAY ISSUE 5 • 2011 • DIGITAL COMSTOCK/THINKSTOCK

Table of Contents for the Digital Edition of CMSA Today - Issue 5, 2011

President’s Letter
Case Managers are Critical to Decreasing Fragmented Care
A Caregiver’s Emotional Journey Helps in Development of Valuable Case Management Resource
A Managed Care Poem
Case Managers in the Spotlight: The Impact of Case Management on Nursing Leadership and Health Care
CMSA and NASW Launch the CMI Case Load Capacity Calculator
Health Plan Accreditation and Health Care Reform
Association News
CMSA Corporate Partners
Index of Advertisers

CMSA Today - Issue 5, 2011