Objectives
1. Describe at least 4 responsibilities of a case manager or care coordinator.

2. Identify 3 benefits to the patient of coordination of care.

3. Describe 2 ways in which the nurse can be a patient advocate.

Background
The home health patient frequently has multiple problems, more than one caregiver and several disciplines making home visits. It is important that the care be coordinated so that the patient receives the optimal care needed.

Why Do I As a Home Health Nurse Need to Know This?

The nurse is generally designated as the case manager or care coordinator. As the case manager, the nurse is responsible for ensuring the continuity of care, assisting the patient and family in accessing resources and promoting quality outcomes.

Content

1. Case/Care Management Responsibilities
The case manager is responsible for:

A. Coordinating the care given by all the disciplines.

B. Conferring with the physician in developing the initial care plan and goals for the patient.

C. Developing and implementing the care plan based upon, physician orders, patient assessment and input from the team members.

D. Revising the care plan in consultation with the physician and based on ongoing assessments.

E. Facilitating access to community resources.

F. Solving problems as they arise with patient care.

G. Collaborating regularly with all team members in implementing the plan of care.

H. Coordinating discharge planning based upon patient needs.

2. Teamwork
It is very important for the care team to work together. The team includes the patient, family members, physician, and all involved disciplines from the home health agency. In some cases, it may involve staff from another community agency. Ongoing communication among all members is vital to giving excellent quality of care and having good patient outcomes. Each team member is responsible for:

A. Keeping other team members informed of their assessments, care and goals.

B. Documenting all communication accurately and in a timely manner.

C. Participating in multidisciplinary case conferences.

D. Working towards common goals to achieve good patient outcomes.

E. Monitoring the patient's condition and notifying other team members immediately of changes.

F. Coordinating discharge planning with the case manager.

G. Meeting patient and family expectations towards established outcomes

3. Benefits of patient care coordination
There are several benefits in good coordination of care. They include:

A. Improved patient outcomes

B. Smooth transition of care

C. Improved satisfaction by the patient, family, physician and other staff,

D. More efficient resource utilization

E. Reduction of cost.

4. Patient Advocacy
The nurse provides a climate in which the patient and family can act in their own interest and intervenes if they are unable to act in their own interest. The case manager is an advocate for the patient. In an advocacy role the nurse:

A. Ensures that the patient understands his/her rights and responsibilities and that care is provided ethically.

B. Sometimes advocacy involves guiding the patient through the complex health system.
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