Acknowledging that each individual case is different within its specific merits, some critical commonalities exist regarding the successful management of any catastrophic case. These commonalities include the perspective of healthcare providers and their associated facilities, as well as the perspectives of the individual patient and his or her family. A catastrophic Nurse Case Manager is a key player in helping to successfully manage a catastrophic injured patient/worker.
Cost represents the pinnacle concern and the top influencing factor in patient care — not just the costs incurred by the health care organization, the associated health care professionals and administrative staff, but also the costs for the patient as well (unless the injury is work related).
While patients are obviously thankful for receiving quality healthcare, the doctors, nurses, staff members and other providers — and even any equipment present — all look like dollar signs when viewed through the eyes of the attorney, insurance adjustor, and patient, or their family.
It is easier for the health care provider to see and understand the needed costs and long-term benefits of care. Patients, their advocates, and non-medical participants find seeing these benefits more difficult. Providers must manage costs carefully, keeping in mind the importance of the cost-benefit relationship.
By communicating these benefits effectively with the patient and his or her advocates, the physician increases patient compliance with the long-term recommendations. This transparency also builds confidence among insurance adjustors, attorneys, and other patient advocates regarding the quality and appropriateness of the provided healthcare strategy.
This communication must bear a tone and quality that the patient, and his or her advocates, can readily understand. Providers that lack proper bedside manner, or the ability to convey the relevance and appropriateness of care, almost guarantee that the patient and patient advocates will balk at the recommended long-term care strategy. This is especially true when high dollar strategies are requested for extended periods of time or for chronic problems/conditions.
For successful management of the catastrophic case, the patient and all involved advocates must have full disclosure regarding all aspects of the case involving their health, treatment plans and recovery — from start to finish.
Availability and Caring
Patients and their representatives greatly benefit by participating in transparent communication between the attending staff and other caregivers. Transparent communication refers to the availability of staff to competently answer questions and address concerns in a suitable, satisfactory way and in a timely manner.
This transparency and availability of staff to offer support that proves transparency of care, quells many fears, foments compliance, and creates an environment of caring. Patients know that they are being cared for, but do they know that anyone cares?
In outpatient settings, the NCM is often the participant that helps to convey this best. She is surely the conduit for most, if not all the parties involved on a case.
Does the patient feel, cared for – truly and competently cared for?
If they do not feel truly cared for, they will surely convey these concerns to their representatives/family/friends, causing a host of potential problems for the health care team, associated facility and/or insurance payor.
As members of the health care team work feverishly to provide the best care, providing the most options at the lowest cost for the patient, insurance company, and his or her advocates is CRITICAL. Concerns over dollars should never come before quality care. The patient vacillates from concerns about their injuries/conditions to concerns about the care they are receiving, objective oversight provided by a designated individual is critical.
That Nurse Case Manager oversight must include all five of these factors discussed. That includes costs, communication, caring, availability, and evaluation. The patient wants and needs these things — things that let them know they are safe and secure, especially after experiencing a catastrophic event. The health care providers want the patient to experience as full a recovery as possible, including the necessary completion of all follow-up services and requirements. And lastly, the payor must also fully understand the information so that care/treatments are justified and appropriately authorized.
A competent case manager makes certain, through her fastidious and ongoing evaluation of the process, that the patient receives these critical aspects of care at the best available cost to the principals involved.
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