Case management refers to a collaborative process that includes assessment, planning, and coordination of options and services to meet a patient’s medical care needs (California Hospital). This paper is going to explore SSM Health Centers’ case management program. The program will be compared to that of Utah State Hospital with an aim to validate whether the facility adheres to recognized standard for case management. There will be determination of whether the facility’s quality assurance program results in the patients being helped to maximize their health care benefits. There will be suggested areas for improvement by giving recommendations aimed at improving the quality of patient care.
SSM Health Centers’ case management program
The case management program at SSM Health Centers is free for those who are diagnosed with chronic health conditions or have complex health care need (Deancare). One is provided with a registered nurse who becomes the resource person for the patient. The case manager works with the patient, the patient’s health care provider as well as others involved in health care so that the best plan of care is established (Deancare).
Identification for case management is based on diagnosis, acute injury, or referral from a health care provider (SSM Health). An individual can also request case management services. The benefits of enrolling for case management are that one is assured of receiving the most appropriate health related services for the condition he or she has. The best plan of care done in collaboration with a person’s health care provider and the health care team is created and a high quality cost effective care options are identified for the customer (Deancare). In addition, supportive health care and community resources are found for the patient. The patient is thus assured of support and resources that meet his or her health care goals. There is also the benefit of getting education and outreach services that promote a healthy lifestyle (SSM Health).
The role of the case manager at SSM Health Centers includes evaluating insurance coverage while managing the utilization review process from admission to discharge. He or she reviews comprehensive patient treatment plan. It is also the duty of the case manager to collaborate with physicians and other health care professionals regarding the patient plan of care and intermediate care goals, which work according to proposed timelines. He or she reviews and evaluates discharge and schedules follow up appointments. It is the work of the case manager to evaluate insurance coverage for optimal use of benefits. The case manager is supposed to interview the patient or family members in order to obtain a complete social history and financial information, which is communicated, to external case managers to receive authorization for payment (SSM Health).
Comparison of the facility’s case management to that of Utah State Hospital
The goal of Utah State Hospital case management program is to define and provide uniform and consistent practice guidelines for case management programs serving consumers with mental illness in community mental health centers in Utah (USH). This is done on the recognition that consumers have basic needs and should have access to eligible services to meet their needs (USH).
The case management at Utah State Hospital is provided in the community rather than in an office setting. The services may be provided in the client’s home, work place, shelter or on the streets among other settings. The service is provided in the belief that recovery is possible (USH). The program not only observes the manifest symptoms of the illness but also psychosocial problems such as housing, transportation, application and attainment of entitlements, attainment of food activities for daily living, medical appointments among other things (USH). The program is client centered, consumer empowering, racially and culturally sensitive and focused on strengths (USH). Case management is based on request and customer preferences. Therefore, consumer’s self direction should be respected (USH). There is concern for safety in provision of case management services. Believes, values of people as well as legal issues are also referred to (USH).
Compared to SSM Health Centers Utah State Hospital case management program is more comprehensive. SSM Health Centers’ program is also wide and has so much in common with Utah State Hospital’s program. The only difference is that SSM Health Centers’ program more focused on those with chronic conditions and those in need of acute care.
The program at SSM Health Centers meet the recognized standards for case management which include case management, consumer education and engagement, staff training and qualifications, case management assessment and plan, care coordination, transitions of care among others (urac). There is adequate consumer education at the SSM Health Centers and all the case managers are qualified personnel. Coordination of care is observed and there is an elaborate plan for follow up of patients after discharge.
In this regard, SSM Health Centers’ quality assurance program enables the patients to maximize their health care benefits. It is the duty of the case manager to evaluate insurance coverage so that the patient receives optimal benefits. The program identifies high quality cost effective care for the patients. It is therefore right to conclude that the quality assurance program at SSM Health Centers helps the patients to maximize on their health care benefits.
Recommendations for improvement
SSM Health Centers’ case management program can be said to offer its clients valuable services. However, there are areas of improvement that need to be considered to offer patients the best care. The program need to be community based rather than follow an office setting. This is in order to reach many members of the community. There is also need to include other conditions other than chronic conditions and acute care needs so that many people receive the best quality health care and maximize on their health care benefits. Finally, the program needs to be client centered and ought to take into consideration the culture of the clients.
SSM Health Centers are model health care providers. The case management program at the facility having met the recognized standards is worth emulating by other health care providers. Compared to other renowned health care providers, SSM Health Centers case management program fairs well. There are however areas that need improvement and these need to be evaluated so that the patients who go to the facility receive the best care. Overall, the facility has shown the way as far as health care is concerned and their case management program ranks as one of the best in terms of enabling patients receive maximum benefits from their health care. Qualified case managers make the facility a model health care provider for all.