EXAM 2 Objectives
Continuity of Care
Chapter 15 Objectives: case management
1. Define continuity of care, care management, case management, care coordination, transitional
care, integrated care, social determinants of health, and advocacy.
oContinuity of care- ongoing care
oCase management- a collaborative process of assessment, planning, facilitation, care
coordination, evaluation and advocacy for options and services to meet client needs;
uses communication and available resources to promote safety, quality of care, and cost
effective outcomes
i. Purpose= improving care coordination and reducing fragmentation of the
services
ii. Case management practice= complex because of the need to coordinate
activities of multiple providers
1. More complex in rural settings due to fewer organized community based
systems, geographic distance to delivery, population density, finances,
pace and lifestyle, values, and social organization differences
iii. Goals:
1. Promote quality services provided to clients
2. Reduce institutional care while maintaining quality processes and
satisfactory outcomes
3. Manage resource use through protocols, evidence based decision
making, guideline use, and disease management program
4. Control expenses by managing care process and outcomes
oCare management- health care delivery process that helps achieve better health
outcomes by anticipating and linking populations with the services they need more
quickly; care management strategies developed by HMO
i. Purpose = to promoted quality and ensure appropriate use and costs of services
ii. Strategies include: utilization management, critical pathways, case management,
disease management, demand management
oCare coordination-
oTransitional care- bridges the gaps among diverse services, providers, and settings
through the systematic application of evidence-based interventions that improve
communication and transfer of information within and across services, enhance post-
acute care follow up, and decrease gaps in care by using a single consistent provider
oIntegrated care-
oSocial determinants of health-
oAdvocacy- one who acts on behalf of or interceded for their client; achieve engagement,
and promote self-determination and patient empowerment in a client (informing,
supporting, and affirming)
2. Describe the scope of practice, roles, and functions of a case manager.
oScope of practice-
oRoles- assessor, planner, facilitator, coordinator, monitor, evaluator, advocate; broker,
consultant, educator, mentor, negotiator, researcher, systems allocator
oFunction- uses communication and available resources to promote safety, quality of care,
and cost effective outcomes
3. Compare and contrast the nursing process with the process of case management and advocacy.
oCommunity assessment, policy development, and assurance activities
4. Identify methods to manage conflict, as well as the process of achieving collaboration.
oConflict management techniques:
i. Using a range of active communication skills directed toward learning all parties
needs and desires
ii. Detecting areas of agreement and disagreement
iii. Determining abilities to collaborate
iv. Assisting in discovering alternatives and activities for reaching a goal
