Case management (USA health system)

Case management (or case management or case management or case management ) refers to a flow chart in social work.

The goal in case management is a well -organized and demand on the individual case, tailored assistance in which the health care needs of a client or patient is provided. The overall support is planned as a performance both over a defined period and across existing borders of facilities, services, offices and responsibilities, implements, coordinates, monitors and evaluates. The case management complements the system management, which is not related to the individual case, but also relates to the parties to the welfare institutions of supply systems in the context of social security systems.

The social work method was borrowed initially as an extension of individual assistance ( Casework ) developed in the USA and found in Germany in recent years been increasingly included in the intervention strategies of social work and health care. Most recently, case management for central lever of the implementation of the Hartz IV laws with regard to the care and labor integration of ALG II recipients. One of the pioneers of this method is Wolf Rainer Wendt.

Working as a case manager can be referred to as clinical in preparation and support of integrated care social work. This professionally differentiated social work is dedicated to

• Direct work with clients and patients
• Difficult social and psycho-social disorders, social problems and psychological, somatic and chronic diseases with significant social implications
• Health work with intensive involvement of the social context.

• 5.1 Definition by laws
• 5.2 Appropriateness of decisions dependent case manager
• 5.3 Enforcement of Legal Claims
• 5.4 Monitoring, Verification and Auditing
• 5.5 Criticism of the employment promotion
• 5.6 Criticism of the system of DRGs

• 6.1 Literature

Basic characteristics of case management

Case management leads to goal achievement basically two systems together:

In both systems, there is a variety of action - support and control requirements that must be most effectively linked to the promotion of the client.

Routing the halyard to the "vertical " individual level runs over different phases:

• Consulting - Case Recording and profiling / assessment
• Planning - goal setting and care planning
• Intervention - implementation, power control
• Monitoring - monitoring and optimization
• Evaluation - Evaluation of results and documentation

In the " horizontal " institutional system aims to:

• Demand and inventory
• Labor market analysis
• Action planning and control
• Supplement the available services offered
• Development of cooperation networks
• Process costs in accounting and controlling the service provider and the cost object

In this field of complex conditions for action needy should receive especially with multiple loads tailored to their personal problem assistance in the form of a coordinated package of measures. A key element here is the active involvement of stakeholders in the planning, goal setting and implementation and not " Tarpaulin " and management of cases.

Application of case management

Case management is generally applied by all known books of the Social Code. The applications are known, for example by:

• SGB ​​II for the reintegration into employment
• SGB ​​V for the care of patients in the integrated care
• SGB ​​XI under the care or counseling in the nursing bases
• SGB ​​XII for the reintegration into working life
• Etc.

Functions of case management

Case managers assign different functions to in English literature.

Advocacy / lawyer

In the function of the Advocacy ( Advocate ), the case manager is committed to the interests of his clients and inform them of their rights. He is advocating for the people to the side, the face conflictual life situations (eg, poverty, lack of education, disability) or unforeseen biographical life crises are not (eg, accident, unemployment, serious illness ) in a position to their personal interests on the basis of short-, medium - or to make long-term individual need for assistance and / or socio-political powerlessness law.

Broker / Dealer

As a broker of case managers between the supply system and the client provides objective, impartial and independent. This broker or intermediary function is a response to the confusion and disintegration of today's complex and highly social division of labor and health care systems.

Gate-Keeper/Torwart

In the function of the gate - keepers of the case manager is responsible for the appropriate use of available resources of the system - it controls the access to the services and reviews the selection and the effectiveness of measures taken. The gate - keeper to counteract by careful selection and ongoing monitoring of inappropriate and non-directional use of the resources of the supply system. From this sometimes result in decision conflict. Background of the gatekeeper function is the idea that the targeted access control provides the most benefit for the overall system (eg, for medical care ).

Case management in practice

In health care, the provisions of the Nursing Act and the Naturopaths Act. Thereafter, a case manager without appropriate qualification as a nurse without permission or authority to make a medical practitioner no independent findings on the health of a patient. In all other task fields no restrictions are determined by laws for case management.

The case management process

The course of the case management process is described by the various authors in different ways. Example here is the control loop, as published by the German Society for Care and Case Management ( DGCC ).

• Definition of Wendt ( 1999):

Case management is a collaborative process in which assessed, planned, implemented, coordinated and monitored and options and services will be evaluated. Thus, the health needs of a person by means of communication and with the available resources is satisfied in a high quality and cost-effective manner.

• Definition of DGCC (2008):

Case management is a process of interdisciplinary collaboration in patient care across all departments of a hospital and beyond. It includes the assessment, planning, documentation, coordination, organization and evaluation of health services. The individual's medical and nursing requirements ( Help and support requirements) of a patient are determined and scheduled by the Case Manager with the patient. The Case Manager detects the prospective needs for care with the support of an appropriate assessment instrument. The Case Manager accompanied the course of treatment of a patient under the aspects of quality assurance and cost control. It organized primarily internal processes of the hospital. Are involved in pre-and post-inpatient processes, they are also organized by the Case Manager. Patient care is the individual, professionally and scientifically recognized need of appropriate, ie " indexed " to services with sufficiently robust net benefit restrictive and professional care is a demand- supply.

Organization of institutions

In the cross- sectional dimension of the case management area must be connected to each other, between which there has been no cooperation structures. Networks of cooperation between social partners in the public and non- carriers are only tentatively emerged in recent years and often far away to have lasting cooperative relationships on individual projects. The range of measures is not always sufficiently well developed regional and labor market brings due to the introduction of a new method of care and placement produced no new jobs.

Individual rehabilitation plan

The implementation of case management encounters in practice, barriers and boundaries. In health care, were first in the field of rehabilitation and later also with respect to control of chained power elements of several performers during lengthy illnesses elements of case management. So to be developed an overarching rehabilitation plan in which the various treatment steps are integrated from inpatient to outpatient treatment.

Case management by the family doctor

To save costs and avoid multiple examinations for diseases to his team take over the case control in the event of illness a doctor. To efficiently achieve this objective, for example, must

• Patients are adequately motivated to participate and to be able
• The participating teams of family doctors are trained
• Appropriate guidelines for the integrated treatment will be made available
• Be in accordance with appropriate compensation of the family doctor
• Effective auditing are set up for the success of the measures.

As long as the various systems such as inpatient and outpatient therapy are insufficiently linked, this requirement remains unfulfilled. For the parties results in additional expense as soon as various payers are involved. Furthermore, in this approach, the social and the professional environment remain excluded. In addition, the initiative and activity of the patient tends to be restricted as encouraged by the variety of rules. The effectiveness of the setting in terms of outcomes for the patient and for the insurance provider for the time being remain doubtful beyond pilot projects.

Criticism of the legal understanding to case management

The concepts of system management and case management are distinguished frequently neither useful in the German practice yet defined separately in the discussion. The duality of system (English: system ) and case (English: case ) is never explicitly mentioned. Thus, the terms and their responsibilities to the system and the case can not be distinguished or go colorful addition to and through each other. There is also a responsibility for properties of nested systems is not clearly supported either for the hospital system, or for the system or for the social health care system. Also the case to a superset of the definition space of the system. Elsewhere, terms case management and case management are linguistically dissonant defined by the following recursive Reason: The concept of case management is applied in the most diverse fields of social and health services. Continuity of action for the design of the certificate course (Certificate of Advanced Studies / CAS ) is of the opinion that Case Management includes both Fall and system management. Or the concept of the system appeared in the text of the law at best as a data processing system, however, the term of the case, only in legal descriptions for limiting power, as individual cases ( SGB X § 7 sentence 1 Management fee SGB X § 20 sentence 2 Principle of Investigation ), omission (SGB X § 20 sentence 2 principle of Investigation ) case distinction and in conditional clauses with " if ", otherwise, ceased to exist, etc.

Defined by laws

The Case Manager will initially represents the interests of his employer, employer or client. The interests of the clients or patients always remain subordinate. The role of the case manager is just as defined as the order in case management.

The full text search in the database of West German law provides at best a hit to liberation facts of social security systems for federal employees in Hong Kong. but no hit on the concept of case management or case manager or general manager beyond modern concepts of vocational training (as at 30 May 2010). The German colloquial term of Kümmerer is at best understood in connection with disturbances in piglet rearing.

Appropriateness of decisions dependent case manager

Due to the largely open performance obligation remains far to interpretation laws, regulations and administrative provisions conducting audits according to DIN EN 19011 to be expected in case management services in Germany hardly. An ever increasing number of complaints before the social courts is a clear indication.

Enforcement of a right

The problems in the civil service law with poor performance were first more than 130 years after the introduction of the Civil Code with the renewed contract law (see BGB § 280 et seq, damages for breach of duty ) treated, and this is hardly applicable for public bodies within the scope of the Administrative Procedure Act. Thus, the role of the case manager as the objective of case management is as previously defined and therefore not a court of law enforce no standards of care for the individual case.

Observation, inspection and auditing

The usual in American organizational units functions of the observation (English: monitoring), monitoring (English: surveillance ) and the Auditing ( according to EN ISO 19011 ) degenerate in the German practice to superiors and thus for the exclusive binding to the responsible management instance. Thus, an independent review of the achievements and the quality of work in case management is not established.

Criticism of the employment promotion

In the area of ​​employment promotion in the context of the Hartz IV Implementation of case management is first discussed with a further claim. But problem areas are also now clearly visible. With case management entrusted employees in the employment agency or the social services of the local authorities require much more design and decision latitude than for their previous work for this task. Additional qualifications, supervision and a supportive working environment are essential, even supervisors who recognize and support the meaning and claim the procedure.

Criticism of the system of DRGs

Except to the common word element of the case flat rates remain beyond the case management. They merely serve to control the settlement after a performance after their production and not even touch the booking. The encoder, which deals with the case flat, has nothing to do with the case management.