What are the most effective ways to manage patient care in a home care setting?

Home care is a growing and complex field that requires effective case management to ensure quality, safety, and satisfaction for patients and caregivers. Case managers play a vital role in coordinating and facilitating the delivery of services, resources, and support for patients who receive care at home. However, home care also poses unique challenges and barriers that case managers need to overcome. In this article, we will explore some of the most effective ways to manage patient care in a home care setting, based on best practices and evidence-based guidelines.

1 Assess the patient's needs and goals

The first step in managing patient care in a home care setting is to conduct a comprehensive and holistic assessment of the patient's needs, goals, preferences, and strengths. This involves collecting information from various sources, such as the patient, the family, the primary care provider, and other health care professionals. The assessment should cover the patient's medical, functional, psychosocial, environmental, and financial aspects of care. The case manager should also identify the patient's level of risk, acuity, and complexity, as well as any potential gaps or barriers in care.

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Robert Bowman

Basic Health Access
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Continuity primary care with more and better delivery team members is required, but is denied for most Americans by Medicare, Medicaid, and private payers. This is most evident in 2621 counties lowest in health care workforce since forever where 45% of complexity is found in this 40% of the population with only 25% of each of primary care, mental health, and womens health workforce supported poorly with less than 20% of spending in each. These counties have concentrations of elderly, poor, disabled, and worst employers shaping highest concentrations of worst health insurance. Medicare 2011 data documents 15% lower payments to these practices. All of these six steps are prevented or inhibited by CMS, Congress, states, and private payers.

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2 Develop a care plan and monitor progress

Based on the assessment, the case manager should develop a care plan that outlines the services, interventions, and outcomes that are appropriate and achievable for the patient. The care plan should be individualized, patient-centered, and collaborative, involving the patient, the family, and the care team. The care plan should also be flexible and adaptable, allowing for adjustments and revisions as the patient's condition or situation changes. The case manager should monitor the patient's progress and satisfaction regularly, using tools such as telehealth, home visits, or phone calls.

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Robert Bowman

Basic Health Access
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Step 2 is most important, but this ideal is challenged by the reality. Fewer and lesser delivery team members as well as deficits of primary care, mental health, and social supports make this challenging for most Americans. Hiring a case manager is difficult due to poor finances. CMS gives these team members more tasks forcing more multitasking that defeats care, caring, and the heart of health care delivery - the one on one with patients, caregivers, and family. This is the innovation that matters most, individualized as needed, but it is most denied by design. Also the populations have lowest levels of literacies, which translates to person to person contact rather than virtual.

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3 Coordinate and communicate with the care team

One of the main responsibilities of the case manager is to coordinate and communicate with the care team, which may include home health aides, nurses, therapists, social workers, pharmacists, and other specialists. The case manager should ensure that the care team is aligned and informed about the patient's care plan, goals, and preferences. The case manager should also facilitate the referral, transition, and integration of services, as well as the resolution of any issues or conflicts that may arise. The case manager should use effective communication strategies, such as electronic health records, care coordination software, or secure messaging systems.

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4 Educate and empower the patient and the family

Another important aspect of managing patient care in a home care setting is to educate and empower the patient and the family about their condition, treatment, self-care, and resources. The case manager should provide relevant and timely information and guidance that can help the patient and the family understand their role and responsibility in the care process. The case manager should also encourage the patient and the family to participate in decision-making, goal-setting, and problem-solving. The case manager should also promote the patient's autonomy, dignity, and quality of life.

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5 Evaluate and improve the quality of care

The final step in managing patient care in a home care setting is to evaluate and improve the quality of care that is delivered and received. The case manager should use various methods and measures to assess the effectiveness, efficiency, and equity of the care services and interventions. The case manager should also solicit and incorporate feedback from the patient, the family, and the care team, as well as from external sources, such as accreditation agencies, regulators, or payers. The case manager should also identify and implement opportunities for improvement, innovation, and learning.

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6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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What are the most effective ways to manage patient care in a home care setting?

1

2

3

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1 Assess the patient's needs and goals

2 Develop a care plan and monitor progress

3 Coordinate and communicate with the care team

4 Educate and empower the patient and the family

5 Evaluate and improve the quality of care

6 Here’s what else to consider

Case Management

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What are the most effective ways to manage patient care in a home care setting?

1

2

3

4

5

6

1 Assess the patient's needs and goals

2 Develop a care plan and monitor progress

3 Coordinate and communicate with the care team

4 Educate and empower the patient and the family

5 Evaluate and improve the quality of care

6 Here’s what else to consider

Case Management

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