Discharge Planning under the Umbrella of Advanced Nursing Practice Case Manager
In Canada, development of the nurse practitioner role evolved because of a predicted physician shortage and a decrease in federal government funding (de Leon-Demare et al. 1999). These factors forced the provinces to look at alternative healthcare delivery models. In the US healthcare system, the primary driving force was cost containment and resource utilization (Kersbergen 1996; Cohen and Cesta 1994) imposed by the US federal government. The role of case manager is now successfully used across many practice settings in the United States. The nurse who is a case manager has many abilities, and the role itself requires many functions.
It is the author's contention that the nurse as case manager has many of the same characteristics and functions that the ANP role has. The purpose of this paper is to compare the advanced nursing practice role to the acute care nurse case manager acting as discharge planner to determine whether case management fits the definition of an ANP role. In the course of discussion, a definition of case management, historical development of case management and criteria of ANP in relation to case management will be discussed. As well, domains of ANP in relation to case management, potential for ethical dilemmas, future roles of case management and a model for evaluation of this role will be explored.
Case Management DefinedWhile there is no standardized definition of case management, there are similar underlying themes in the literature. In the broadest sense, case management has two focuses. The first is client centred, aiming to provide the best care to an individual through coordination, education and access to services (Lyon 1993). The second is system centred, which aims to reduce system costs, lengths of stay and readmission (Lyon 1993). Kersbergen (1996) defines case management as "maintain[ing] quality of care while controlling the costs of health care through coordination and management of care." Bower (2004) describes case management as simultaneously being a role, a system, a technology, a process and a service. For example, as a system, it encompasses the nursing process when client directed, or it can be a clinical system that focuses on the client outcomes within set time frames (Seuntjens 1995). As a service, case management has both facilitating and gatekeeping functions for clients when accessing health services (Seuntjens 1995; Padgett 1998). Through the process of case management as technology, care maps evolved in an effort to standardize care within diagnoses (Seuntjens 1995). In addition, there is a new emphasis on managing at-risk populations longer in settings other than hospital, thereby reducing admissions (Zander 2002).
Individuals who are admitted to hospital need to go home at some point. Discharge planning from hospital would appear to be a straightforward process designed to ensure that the patient leaves the hospital as soon as possible (Pringle 1999). Often, this is not the case. Dubler (1988: 79) maintains that discharge plans are a complicated "mix of what the professional suggests, what the patient desires, and what the family, community and funding agencies will allow." A case manager assists in smoothing the transition from hospital to community.
History of Case ManagementCase management has roots in nursing, medicine, social work, mental health and public health dating from the 19th century. In Massachusetts in 1863, public funds were used for the first time to coordinate services to the poor and immigrant population (Tahan 1998). This service was initiated in order to stop this group from "cheating the system" (Kersbergen 1996). Later, in the early 1900s, the first home visiting nurse program was developed (Kersbergen 1996).
In 1901, social work championed another model of case management. The social work model tended to be service based, while nursing models were more comprehensive (Tahan 1998). In 1909, Lillian Wald convinced Metropolitan Life Insurance to provide a visiting nurse service to its policy holders in order to prevent the payment of death benefits (Tahan 1998). The program was very successful and was estimated to have saved the company approximately $43 million between 1909 and 1925 (Scott and Boyd 2001).
Following World War II, in response to the need to support veterans with mental health issues, case management began (Tahan 1998). During the 1960s and 1970s, case management evolved in tandem with the civil rights movement, which encouraged individuals to become active participants in care choices rather than passive recipients (Kersbergen 1996). In 1962, coordination for mentally disabled populations began (Kersbergen 1996). It was during the 1970s that the term case management was first used (Tahan 1998).
Case management saw its biggest growth in the 1980s. In an attempt to control costs paid by the US federal government to hospitals, diagnosis-related groupings (DRGs) were imposed and "prospective payment" plans were implemented (Tahan 1998). Hospitals were forced to examine methods of care delivery and began to implement case management models to help with resource utilization (Tahan 1998). Development of clinical pathways and care maps followed similar time lines, beginning in the 1980s (Tahan 1998).
In Canada, the healthcare system has taken pieces of the American system and applied them. Care maps are frequently used, and resource utilization is expected to be appropriate. Funding is not specifically tied to a diagnostic group, but length of stay and cost are examined closely. Care is expected to be delivered in the most appropriate setting. During the late 1980s and into the 1990s, the federal government reduced the amount of transfer payments to the provinces for healthcare funding (de Leon-Demare et al. 1999). This, in turn, forced the provinces to institute change within the healthcare system. The drive to find alternative forms of delivery for primary healthcare services included re-examining the model of advanced nursing practice (de Leon-Demare et al. 1999). As Canadians continue to move towards the need for cost containment within the healthcare system, advanced nursing practice offers a promising role in case management.
Advanced Nursing Practice CriteriaWhile advanced nursing practice is applicable across many settings and disciplines, a broad consideration of areas in which case management applies lies beyond the scope of this paper. The remainder of this discussion will therefore focus on acute care, specifically, discharge planning.
Case management is not specifically described as part of
advanced nursing practice. However, the activities of the nurse
case manager are consistent with the position statement of the
Canadian Nurses Association (CNA) on ANP (2002). This position
statement articulates the following partial list of the
characteristics of ANP that are duplicated in the work of case
- Entails expert and specialized practice grounded in knowledge that comes from nursing theory and other theoretical foundations, experience and practice.
- Involves the deliberate, purposeful and integrated use of in-depth nursing knowledge, research and clinical expertise. It also involves integration of knowledge from other disciplines into the practice of nursing.
- Requires a depth and breadth of knowledge that enables the nurse to provide an ever-increasing range of strategies to meet the complex needs of clients.
- Influences the practice of nurses by facilitating the integration of research-based knowledge into practice.
- Involves planning, coordinating, implementing and evaluating programs to meet client needs through partnerships and intersectoral collaboration.
- Involves the ability to analyze and influence health policy.
- Reflects substantial autonomy and independence with a high level of accountability. (CNA 2002)
These criteria for advanced nursing practice are demonstrated every day in the management of discharges from hospital. In addition, other skills that assist in functions of the ANP role include the ability to
advocate for clients, collaborate with clients, families and other health care workers, assess and plan for client service needs efficiently and accurately, delegate, negotiate, analyze costs and benefits of care, understand the provision of services across the continuum of care, predict client outcomes, collect and evaluate outcome data, and understand financial data and business planning. (Fraser and Strang 2004: 34)
These skills assist in the delivery of care and are closely aligned with the CNA's position statement for advanced nursing practice (2002). Knowledge of outcomes, community resources available and their limitations, coordination of care, collaboration across disciplines, priority setting, flexibility and problem solving in a stressful environment are all functions of the nurse who works as discharge planner. Consequently, it is the author's argument that a case manager acts in an advanced nursing practice role.
Domains of ANP in Relationship to Case ManagementDomains of practice within ANP include direct care, research, education and administration (CNA 2000). Within these domains, a set of competencies serves as a foundation for describing the functions performed in ANP. These competencies are clinician-educator, researcher, leader, collaborator and change agent (CNA 2000). The case manager acting in an ANP role has the ability to function well in all these domains, facilitating better-coordinated and more cost-effective delivery of healthcare services. Further exploration of these competencies follows.
Educational roleIn early conversations with clients, the nurse is able to identify gaps in their daily functional abilities. For the seniors population, for example, knowledge of medications, inability to complete personal care or impaired ability to perform independent activities of daily living (IADL) and activities of daily living (ADL) can be anxiety provoking and stressful. On admission to hospital with an acute, episodic illness, many seniors fear they will be "put into a home." Add to this fear a hospitalization that may result in new diagnoses, changed or additional medications, strained family support, possibly minimal teaching and a discharge that is much earlier than anticipated, and it's no wonder seniors feel "anxious and afraid" (Pringle 1999). The case manager may be able to determine influencing factors in the environment and begin to educate the senior about the changes in his or her health status, services in the community and levels of care available. While a short hospital stay is insufficient to complete all education, a community nurse case manager can continue client teaching after discharge home. Knowledge that support is available to the individual goes a long way towards decreasing clients' anxiety about going home and facilitates discharge in a timely manner.
Research opportunitiesPringle (1999) has identified the dearth of models for discharge planning. Most were not theoretically based and did not monitor how well the discharge planning process was implemented (Pringle 1999). Corser (2003) has suggested that much of the discharge planning literature is largely anecdotal. Wells et al. (1999) have proposed an integrated model of discharge planning that incorporates seven elements:
- The patient is at the centre of the discharge planning process.
- Discharge planning is directed by a discharge manager.
- Family members, attending physician and a community professional are core participants in discharge planning.
- Other health professionals are involved in discharge planning only as the need arises.
- Efficient communication systems are required to support discharge planning.
- The time trajectory of discharge planning and the patient's clinical and social situations are linked.
- A detailed protocol facilitates discharge planning. (Wells et al. 1999)
The development and research of a standardized plan to facilitate discharge planning is one potential topic for future research. Use of a case management approach in the direct care of individuals with chronic health conditions also generates potential research questions.
LeadershipThe role of case management offers the nurse many opportunities to be an effective leader. The ANP role as discharge planner acts as a link between hospital and community. Pringle (1999) recommends that each hospital develop a discharge planning process that is integrated with home care programs. The ANP case manager can be a visible leader in innovations associated with primary healthcare. In addition, ANP involvement offers the opportunity to assume leadership in improving the quality and efficiency of care provided to individuals (Seuntjens 1995).
Collaborative rolePhysicians are generally regarded as the team leaders in the discharge plan, as they are legally responsible for discontinuation of acute care. However, physicians tend to play a minor or invisible role in the actual discharge process (Pringle 1999). McWilliam (1992) has identified that poor communication from home care about coping and the services that are already in place, as well as family influences, often delay discharge from hospital or make the process disjointed and ineffective. The ANP case manager could successfully collaborate with physicians to provide realistic time lines and identify barriers to discharge. This collaboration would assist with establishing tentative discharge dates soon after admission and keep the physician informed regarding services available, thus making the transition to home more likely to succeed. If the physician develops confidence that discharges will occur smoothly, then future collaboration becomes easier. Such development of trust takes time to achieve.
Facilitating changeChange within the healthcare system is fundamental. It is always ongoing and can be difficult and confusing. The ANP case manager is in an ideal position to be a positive change agent. The case manager is able to synthesize disparate information and competing demands and identify options for the client, family and caregivers to review. The ability to document and research questions regarding care and then present them in a logical manner are powerful tools in institutional change. Understanding the power structure within the hospital bureaucracy and determining who can assist in positive change are fundamental to implementing change.
ANP: Advocate or Gatekeeper?If the case management function is viewed as client and system centred, a potential for ethical conflict soon becomes apparent (Lyon 1993). Padgett (1998) argues that case managers are expected to be accountable to both client and system. The case manager's function is to promote the often contradictory goals of greater system efficiency and client empowerment, more standardized care and more individualized care, tighter control of resources and greater client access to services (Padgett 1998).
A more cautious perspective is slowly replacing the rosy optimism that case management will solve all the system's problems. In this view, potential conflict between goals is acknowledged; recognition is given to the need for good communication skills, tact, diplomacy and a balance between clients' needs and the system's imperatives (Padgett 1998). For the advanced practice nurse, balancing the roles of advocate and gatekeeper becomes more complicated by the fundamental power structure within the hospital. With physicians having the final word regarding discharge, treatment or choices, striking a balance can potentially become even more difficult. Still, advanced practice nurses' expertise in collaboration, education, research, practice, problem solving, leadership and management (Donagrandi and Eddy 2000) makes them well suited for the role.
Future Roles for Case Management in the CommunityThere is a growing expectation that care be delivered in the most appropriate setting. For some clients, that is in hospital; for others, it may mean sub-acute, hospice, transition, community or continuing care. In Alberta, recommendations have been put forward by the Long Term Care Review (Alberta Health and Wellness 1999) that suggest, among other things, a single point of entry into continuing care, and managing individuals longer in non-hospital settings. In the United States, there is a growing trend to specify disease groupings that should be managed without hospital admissions, for example, chronic health conditions such as CHF, COPD, hypertension, diabetes or bacterial pneumonia (Zander 2002). In fact, admission to hospital to treat one of these diagnoses is considered a "failure" to treat appropriately in other settings (Zander 2002).
This view has implications for the future of acute care and the community. With respect to acute care, it means that people in hospital will have higher acuity than currently, because admission to hospital means you are no longer able to manage without high levels of nursing support. With regard to the community, higher levels of nursing surveillance, home support and medication management than are currently available would be needed. For the case manager acting as discharge planner, there is greater need to link individuals to required services and recognize when needs are greater than available supports. At times, the burden of care will fall on family members, and this factor needs to be considered in the discharge plan. For advanced practice nurses in the community, there is great opportunity to assume an expanded role with target populations in order to maximize individual health and prevent exacerbations of chronic illness. It must be recognized, however, that disease conditions fluctuate according to many factors and that even with the best care, hospital admissions may occur.
Evaluation of the ANP Case ManagerWhile the most obvious item to evaluate when looking at case management and discharge planning is hospital length of stay, many other things in the process must be considered. Length of stay is quantifiable; numbers are either better than before or they are not. What other impacts does discharge planning have on the care team? When determining the role of the case manager as discharge planner, it must be recognized that the client is central to the plan. Ideally, client satisfaction in understanding the plan and its goals, as well as decreasing client anxiety associated with discharge, should be deemed important in the evaluation.
ConclusionWhile not specifically described in the CNA's position statement (2002), the role of case manager as discharge planner fits well into the domains and competencies listed for advanced nursing practice. Historically, there have been many changes to case management over the last century, and the future of ANP and case management is diverse. The opportunities for case management in populations with chronic disease in a community or continuing care setting are great, and may lead to better managed health of individuals. The Canadian healthcare system can sustain itself only by identifying creative ways of managing high-risk groups through the use of case management in advanced nursing practice. The ANP role utilizing case management could be key to providing primary healthcare to many individuals with a chronic health condition in a cost-effective manner. While this approach is not without conflict and problems, the way to the future appears to lie in building trust within teams of care providers, with the advanced practice nurse in a leadership role.
About the Author(s)
Linda Cawthorn, RN, BScN, MN (Can.)
Community Care Intake/Hospital Discharge Planner
Westview Health Center
Stony Plain, AB
For more information, contact the author at: Linda Cawthorn, Westview Health Center, Stony Plain, AB, Email: LindaCawthorn@cha.ab.ca
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