Case Management vs. Interprofessional Practice in Nursing

Introduction

Nursing care models serve as important foundations for decision making within the care environment. They influence the scope of tasks nurses engage in as well as how nurses relate to other healthcare professionals and patients in the course of care delivery. Though there may be no one-size-fits-all model, choosing the appropriate model — depending on factors such as the nature of the organizational setting and the availability of resources — is crucial. An effective model is important for achieving the desired patient, staff, and organizational outcomes.

This paper discusses the use of two care models in the care setting: the case management model and the interprofessional practice model. The aim of the paper is twofold. First, a description of the case management model as used at a practice setting known to the author is provided. Next, the paper recommends the interprofessional practice model as an alternative model that could be implemented to enhance nursing care quality, safety, and staff satisfaction.

The Case Management Model of Care

The case management model is one of the more common nursing care models. Unlike most other models, its focus is on patient-centered care rather than the nurse-patient relationship (Finkelman, 2016). As the name suggests, the case management model involves assigning each case — or a certain number of cases — to a specific nurse (registered nurse [RN]). This approach is premised on the assumption that patients have complex health conditions and therefore require a case manager to help them navigate the healthcare system more effectively. The role of the case manager is to plan, coordinate, evaluate, and advocate for the entire continuum of care required to meet a given patient's needs (Plas et al., 2012). The case manager may at times work with other healthcare professionals, thereby enhancing interprofessional collaboration (Girard, 1994).

At the author's practice setting, the case management model is prevalent. For most chronic conditions, patients aged 65 and above are assigned to a specific case manager, typically a registered nurse (RN). The RN must have extensive training and knowledge of chronic disease management. The case manager is charged with coordinating every aspect of the care process — from case-finding and assessment to care planning and case termination. Case-finding is generally the first step of the care process. This stage specifically encompasses determining the patient's risk of admission based on factors such as previous medical records. Predictive modeling procedures are employed in determining that risk, and efforts and resources are focused on patients with the highest risk. Typically, a high-risk patient has more than six medical conditions. Each case manager is allocated a caseload of roughly 40–50 patients. Once the caseload is built, the patient's clinical background, physical health, socioeconomic needs, and mental health are thoroughly assessed. This enables the case manager to determine the type of interventions required to address the patient's specific needs.

The identification of interventions occurs at the third step: designing a personalized, evidence-based care plan. An important feature of the hospital's case management approach is that the case manager often works closely with other healthcare professionals in formulating the care plan. More specifically, the case manager collaborates with 4 to 5 physicians as well as other professionals such as general practitioners, pharmacists, laboratory personnel, psychotherapists, and nutritionists. The team meets on a regular basis to ensure all members remain aligned. The case manager also involves the patient and informal caregivers such as family members in the planning process. For the hospital, collaborative decision making is important for creating a more effective care plan and empowering patients. When patients are involved in the process, they feel acknowledged and valued. The care plan serves as the single reference point for all care administered to the patient under case management.

Once the plan is in place, execution begins. This stage is arguably the most critical. The case manager must effectively coordinate every element of care delivery, including medication management, patient education, psychosocial and self-care support, patient monitoring, and communication with patients and their families. Monitoring is a particularly crucial process. Together with the multidisciplinary team, the case manager monitors each patient every two weeks. The case manager coordinates care not only in the hospital setting but also in other settings such as the home, rehabilitation clinics, and community environments. An equally important role of the case manager is to advocate for the patient's needs — ensuring that services and equipment identified in the care plan are provided as stated, and negotiating for referrals to specialists, home care, and acquisition of medication. A case is terminated based on one of the following factors: death of the patient, self-discharge, confirmation that the patient can live independently, or achievement of an acceptable hospital admission risk level.

Outcomes and Advantages of Case Management

Though evidence for the effectiveness of the case management model is mixed, the model has been shown to enhance the experiences of both patients and healthcare professionals (Girard, 1994; Plas et al., 2012). A major advantage of the model is that the responsibility for caring for a specific patient or caseload is assigned to a specific individual or team, which enhances accountability. In other words, in the event of mishaps or inefficiencies, a specific individual or team can be readily held responsible. Additionally, caseloads are thoroughly built to ensure patients receive care and interventions tailored to their specific needs — that is, truly individualized care. The case management model also enhances patient outcomes by ensuring a single point of access, fostering care continuity, and empowering patients to take control of their own condition. These advantages translate to positive outcomes such as reduced hospitalization, decreased risk of readmission, and greater patient satisfaction.

The case management model is beneficial not only for patients, but also for care providers and the organization as a whole. Indeed, the model has been shown to positively affect staff satisfaction (Girard, 1994). For the organization, chronic care delivery costs are minimized as care fragmentation decreases. Some of these outcomes have been observed at the author's organization. In the last two years, for instance, the hospital reduced care delivery costs per patient by 8% — a considerable improvement given the rising cost of healthcare delivery. The hospital has also recorded increased patient satisfaction. Despite its advantages, the case management model tends to be most effective when it is a component of a larger care program comprising multiple strategies aimed at achieving integrated care.

The Interprofessional Practice Model

A different care model is the interprofessional practice model. Compared to the case management model, the interprofessional model is relatively new. Interprofessional collaboration or practice is defined as an approach to care delivery characterized by partnership between health providers (Bridges et al., 2011). A key feature of the model is interdisciplinary care. The model particularly recognizes the importance of various professions within the healthcare environment collaborating in the delivery of care (Finkelman, 2016). These professions include nurses, physicians, specialists, pharmacists, physiotherapists, and others, all working together to achieve the desired patient outcomes. Interdisciplinary collaboration enhances care continuity and reliability.

The rationale for the interprofessional practice model stems from today's increasingly complex patient needs (Bridges et al., 2011). These needs span a wide array of healthcare specialties. For instance, a patient may have several medical conditions simultaneously — a cancer patient may concurrently have diabetes, obesity, hypertension, and obstructive pulmonary disease. Additionally, medical conditions have become more sophisticated, warranting more advanced diagnostic techniques and interventions. Moreover, owing to factors such as technological advancements, changing patient preferences, and regulatory shifts, the healthcare environment has changed tremendously. New care delivery models have emerged, such as Accountable Care Organizations (ACOs), retail health clinics, and medical homes (Nester, 2016). Given this multiplicity of complex care needs, relying on a mix of expertise is crucial for achieving the desired patient outcomes (Finkelman, 2016).

One of the major advantages of the interprofessional practice model is that it promotes shared decision making and the sharing of expertise (Bridges et al., 2011). With increased demand for healthcare and the growing complexity of medical needs, healthcare professionals now grapple with challenges such as greater workloads. Yet the importance of delivering effective, affordable, timely, and safe care cannot be overstated. In such a complex healthcare environment, interprofessional collaboration builds synergy, placing healthcare professionals in a better position to deliver care.

Conclusion

Overall, nursing care models provide important guidelines for the delivery of care, and based on these models, care delivery can be improved to enhance patient and staff outcomes. Two prominent care models are the case management model and the interprofessional practice model. The author's practice setting largely reflects the case management model. Nonetheless, given the increasing complexity of the healthcare environment, the interprofessional practice model presents an opportunity for improving care quality, patient outcomes, and staff outcomes. Healthcare organizations must continually engage with the literature to become familiar with newer, more effective models. As the healthcare environment evolves, care delivery approaches must evolve with it.

References

Bridges, D., Davidson, R., Odegard, P., Maki, I., & Tomkowiak, J. (2011). Interprofessional collaboration: three best practice models of interprofessional education. Medical Education Online, 16, 10.

Finkelman, A. (2016). Leadership and management for nurses: core competencies for quality care. Upper Saddle River, NJ: Pearson.

Girard, N. (1994). The case management model of patient care delivery. AORN Journal, 60(3), 408–412.

Nester, J. (2016). The importance of interprofessional practice and education in the era of accountable care. North Carolina Medical Journal, 77(2), 128–132.

Plas, A., Onwuteaka-Philipsen, B., Watering, M., Jansen, W., Vissers, K., & Deliens, L. (2012). What is case management in palliative care? An expert panel study. BMC Health Services Research, 12, 163.