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Course: Oncology Nursing

Topic: Nursing Case Management,

Nurse Manager, and Multidisciplinary Team Roles

The Nurses International Community

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Module Goals

Learners will be able to:

Define case management.
Describe the role of the Oncology Case Manager in a multidisciplinary team when caring for cancer patients.
Describe the role of the Nurse Manager in a multidisciplinary team when caring for cancer patients.
Describe the importance of a multidisciplinary team approach when caring for cancer patients.

While & Hall, 2006

Contact info: info@nursesinternational.org

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Definition

While & Hall, 2006.

The American Nurse Credentialing Center, a subsidiary of the American Nurses Association (ANA), defines nursing case management as:

Nursing case management is a dynamic and systematic collaborative approach to provide and coordinate health care services to a defined population.

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Definition of Case Management

The definition of case management, updated in 2010 and published in the Case Management Society of America (CMSA’s) Standards of Practice for Case Management, is:

“Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost effective outcomes.” (CMSA, 2010)

Leonard & Miller , 2012

Contact info: info@nursesinternational.org

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Nurse Case Manager

“The Case Manager is a professional who manages one or more cases entrusted to him with a predetermined path, in a context of space and time defined” ¹

“Nurse case managers actively participate with their clients to identify and facilitate options and services for meeting individuals' health needs, with the goal of decreasing fragmentation and duplication of care, and enhancing quality, cost-effective clinical outcomes”²

Fabbri, De Maria, & Bertolaccini, 2017
While & Hall, 2006

Contact info: info@nursesinternational.org

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Purposes of Nurse Case Manager

The Case Manager will help to align care by working:

With the Medical Director and nursing coordinator
Coordinate/collaborate with corporate planning
Collaboration with nursing unit coordinators and corporate planning and collaboration with specific pathology group

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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Purposes of Nurse Case Manager

Plan the activities that guarantee the continuous assistance of the cancer patient, through the formulation of a shared path, taking charge, diversified according to clinical, assistance, functional and territorial needs.
Participate in weekly multidisciplinary meetings.
Create and share pathways of the takeover, diagnosis, treatment and departmental research.
Contribute and improve the organizational and assistance conditions in conducting clinical studies.

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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Functions of Case Manager

Facilitate communication with patients and families.
Identify patient care requirements.
Support the development, implementation, monitoring service plan through interdisciplinary collaboration with the team and the patient.
Planner of assistance to minimise or eliminate errors in treatment.
Pay attention to patient needs by encouraging the provision of effective and efficient individual assistance.
Promote education to client and family.

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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Functions of Case Manager

Analyse and synthesize data to define nursing diagnosis or interdisciplinary problems.
Direct the patient to the most appropriate resources and services.
Facilitate access to facilities.
Monitor patient progress through the verification of the achievement of objectives.

Fabbri et al., 2017

Image by, Clipart

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Stages of Case Management

The stages of case management:

Assessment
Planning
Monitoring and
Evaluation of the outcome

Fabbri et al., 2017

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Stages of Case Management

Assessment/Evaluation:

The nurse case manager gathers and analyzes in-depth information to understand the patient’s physical, psychological, psychosocial, cognitive, functional, developmental, economic, cultural, spiritual, and lifestyle need.
Provides valuable insight regarding the patient’s history, as well as how the healthcare system has met their needs.
The evaluation should not be subjective.
It must provide objective information based on observation and the ability to use appropriate tools for a multidimensional assessment.

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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Stages of Case Management

Planning of the interventions:

The nurse case manager develops a patient-centered, evidence-based, interdisciplinary plan of care based upon complete analysis of data.
Collaborates with the patient, family, caregivers, healthcare team, payer, and other stakeholders, as needed, to develop an individualized plan of care.
Represents the central aspect of the function of case manager.
The practitioner must seek the synchronisation of actions.
Arranging them in sequence according to criteria of suitability.

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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Stages of Case Management

Continuous monitoring:

Continuous monitoring should establish to determine if the effectiveness of treatment matches the actual practical efficiency.
Involves the observation of :

The gradual reduction of the symptoms or their evolution,
The appearance of side effects and their impact on overall functioning

Monitoring also includes individual variables such as treatment satisfaction, acceptance of care and personal satisfaction.

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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Stages of Case Management

Fabbri et al., 2017

Evaluation of outcome:

Carried out at the end of the diagnostic-therapeutic procedure.
Evaluation on the correlation between the expected objectives and outcomes achieved.
Unresolved clinical problems must be reviewed,
The case manager, together with the patient, should arrange to take care of remaining issues management to minimise their impact, to avoid relapses and to reduce any possibility of disability

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What Would the Nurse Do?

A pediatric patient who is ventilator-dependent and has a gastrostomy button is scheduled to be discharged to home with visits from a home health nurse.

Prior to discharge, What is the most critical action for the nursing case manager?

Assess the patient’s long term home care needs
Procure the required home medical equipments
Verify that the patient is being discharged to safe environment
Secure funding sources for home health care

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Role of Nurse Manager

There are three aspects of nurse manager role:

Financial
Managerial
Clinical

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Role of Nurse Manager

Clinical role:

Application of the nursing process,
Identify the real and potential problems by trying to adapt the plan of assistance to the critical pathway that the case manager has previously developed with a multidisciplinary team and together with this team
Identify any changes in the standards set forth and resolve variances
Devotes part of his time to scientific evidence to promote an advanced type of practice and provide direct patient care type

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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Role of Nurse Manager

Managerial role

To facilitate and coordinate the care of patients.
Together with the interdisciplinary team,determines the objectives and the length of the hospital stay.
Guides the assistance planning the treatment to meet the needs of patients and their families.
Must identify three priority objectives and should determine when team members should be present, taking into consideration the peculiarities of the patient and his or her needs.

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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Role of Nurse Manager

Managerial role

Evaluates the quality of care to ensure the achievement of the objectives with an appropriate use of resources, and identify any opportunities for improvement of quality.
Coordinates the extended care that begins with admission and continues to the follow-up at the patient’s home after discharge.
The quality of care provided and the consequences of treatments and services will be assessed.
The case manager also determines the need for team development and acts as teacher and tutor

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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Role of Nurse Manager

Financial role

This role also has a significant role as an educator to both the health care team as well as to the patient and his family.
Therefore, the case manager must:

Assess the training needs of the health care team and assist the nursing group in the development of protocols and guidelines;
Provide necessary information to the patient and family of how to deal with the disease and to establish new behaviours that are needed;
Have the capacity to communicate and negotiate with a variety of operator.

Fabbri et al., 2017

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

A patient who is homeless has been admitted to the hospital with multiple health care problems. The nursing case manager, physician, social worker, and clinical dietician work together to care for the patient.

What is this interprofessional interaction is referred to?

Collaboration
Consultation
Continuity
Coordination

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References:

American Nurses Credentialing Center (ANCC).Sample Test Questions: Nursing Case Management Sample Questions. Retrieved from: https://www.nursingworld.org/certification/our-certifications/study-aids-ce/sample-test-questions/stq-ncm/

Fabbri, E., De Maria, M., & Bertolaccini, L. (2017). Case management: an up-to-date review of literature and a proposal of a county utilization. Annals of translational medicine, 5(20), 396. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673790/

Contact info: info@nursesinternational.org

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References:

Leonard M., & Miller , E. 2012. Nursing Case Management Review and Resource Manual, 4th Edition 4th Edition. Retrieved from: https://www.nursingworld.org/~4ae0a9/globalassets/catalog/sample-chapters/nursingcasemgmt-samplechapter.pdf �
White, P., & Hall, M. E. (2006). Mapping the literature of case management nursing. Journal of the Medical Library Association : JMLA, 94(2 Suppl), E99–E106 . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463029/#:~:text=Case%20management%20is%20a%20care,continuum%20of%20health%20care%20systems.&text=Nursing%20case%20management%20is%20a,services%20to%20a%20defined%20population.

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