Journal of Gerontological Nursing

Interdisciplinary Care 

Development and Implementation of a Case Management Model for Long-Term Care

Norine E Allen, RN, MS, FNP; Edward Meduna, RNC


Interdisciplinary team members identify the benefits of quality of care and cost efficiency created by greater collaboration among staff and family.


Interdisciplinary team members identify the benefits of quality of care and cost efficiency created by greater collaboration among staff and family.

In the past several years, gerontological nurses have been challenged by the increasing number of elderly individuals who still need a high level of care as residents but are being discharged earlier from acute care facilities. In addition to meeting this challenge, these nurses have been under increasing pressure from payers to identify clinical indicators that quantify the delivery of quality care in a cost-effective model.

One of the major diagnostic challenges for gerontological nurses in long-term care settings is residents with congestive heart failure (CHF). The prevalence and incidence of CHF increase with age. Congestive heart failure is the most common cause of hospitalization in individuals age 65 and older and occurs frequently in nursing home residents (Aronow, 1996).

According to Dente-Cassidy, Mc Van, Mason, and Nornhold (1993), heart failure is one of the most serious consequences of cardiovascular disease, affecting between 2 and 4 million individuals in the United States alone, with a 5year survival rate of less than 50%. Long-term survival is considered poor, despite modern management.

Any illness that forces long-term residents to be admitted and readmitted to an acute care facility may be very disturbing to the individuals, both psychologically and physiologically. Hospital admission may be the event that upsets the delicate balance maintained in frail, impaired, elderly individuals. Older adults may have a multitude of chronic illnesses, may be minimally functional in a nursing home, and may not be able to adapt to the new environment which they may consider frightening. Diagnostic and treatment procedures, meant to cure, can trigger negative reactions that become problems themselves. Hospitalizations can provide a vicious cycle of dependency and permanent impairment (Matteson & McConnell, 1988).

The development of a case management model for long-term care was based on the literature reviewed and a historical review of admissions and discharges in a 420-bed facility. Admission and discharge review of residents admitted with a diagnosis of CHF quickly identified that the facility had substantial discharges either from death or from readmissions to the acute care facility within 30 days of admission to the long-term setting. The discharge rate to acute care facilities in 1997 for residents with CHF was 14.1%. Many of these residents, if they returned to the facility, did not return to their previous levels of functioning.


Case management is viewed as an option that can create a balance between quality of care and the issues of cost efficiency (Haddock, Johnson, Cavanaugh, & Stewart, 1997). The goals of case management include:

* Providing quality care along a continuum.

* Reducing fragmentation.

* Achieving cost containment.

* Increasing quality of life for residents.

Prior to implementation of the case management model, a small task force of three individuals from the nursing department spent considerable time developing a very basic structure and process for the case management model. The intent of the task force was to introduce the case management model as soon as possible to members of other disciplines for input on the continuing development of the model.

Literature on the subject of case management supports the involvement of the entire interdisciplinary team because collaboration among health care providers on integration is essential in providing an effective system for delivery of care (Yockey, Bobier, Harvey, & Spooner, 1997). Therefore, the process of case management and the problem of increased readmissions of residents with a diagnosis of CHF was introduced to the interdisciplinary team.

The initial interdisciplinary team consisted of the nursing clinical coordinator and members from the social services, dietary, activities, and pastoral care departments. The team quickly identified the need for the residents to be part of the process, along with their families, as well as the rehabilitation nurses, occupational therapy staff, and physical therapy staff. This integration and collaboration is a key to commitment of the interdisciplinary team to the goal of keeping residents functioning at their optimal psychological and physiological levels. Other important goals included reducing readmissions to the acute care setting to improve continuity in quality of life, and decreasing cost in manpower hours and in the transfer process.

The interdisciplinary team concluded that because members of the nursing profession are familiar with the case management model, a nurse should be the case manager. A certified gerontological nurse who has excellent clinical and communication skills and is a residentoriented advocate was identified by the team as most appropriate for this role. Nurses in long-term care are ideal choices for case managers because they are frequently the individuals who coordinate all activities related to residents, families, and individuals from other disciplines.

Initially, it was agreed by the interdisciplinary team that the nursing staff would assemble a packet to assist unit nurses in caring for residents with CHF. The packet was used for 60 days on all admissions with a diagnosis of CHF.

The initial packet includes:

* Case Management Procedure (Appendix A).

* Case Management Referral Form (Appendix B).

* Clinical Assessment Record (Appendix C).

* Nursing Clinical Pathway for Residents With CHF (Appendix D).

* Clinical Synopsis of CHF for Nurses (Appendix E) (Hoole, Greenburg, & Pichard, 1988).

* Cue Sheet for Clinical Notes (Appendix F) (Leshem & Varholak, 1996).

* Care Plan (Appendix G).

The results of this trial then were submitted to the interdisciplinary team, followed by further discussion related to the involvement of members of other disciplines. During the initial trial, notification was given to individuals from all disciplines that these residents were being followed by the nursing case manager. The belief was that this procedure would assist the interdisciplinary team members to identify and delineate their responsibility to the residents who currently were being followed by the case manager.


Representatives from all disciplines were introduced to the case management model through a series of inservice sessions including a general overview of case management, the role of the case manager, and an introduction to the initial packet of forms used by the case manager. The second inservice session included a review of the first one and voiced the expectation of increased involvement from the entire interdisciplinary team as roles and responsibilities were identified and then defined by the team. Direct care providers were encouraged to participate and share their firsthand experience with those responsible for the day-today resident care activities (Tahan, 1996).


Residents with a history of CHF were visited by the case manager on admission. The resident assessment was compiled by the case manager, and any recommendations were discussed with the charge nurse. A clinical assessment record (Appendix C), along with a care plan specific to that resident, was placed in the chart. The charge nurse received a folder with a nursing clinical pathway (Appendix D), a clinical synopsis of CHF (Appendix E), and a cue sheet (Appendix F) to assist in documentation related to residents with CHF. The cue sheet was used by the staff between visits from the case manager. Frequency of the visits was determined by the case manager.

The initial response from the nursing staff was the perception of increased work. However, within 2 weeks, charge nurses identified how helpful the case manager and the case management process were with clinical documentation, case planning, and initiating appropriate clinical interventions. The case manager spent time educating families about the diagnosis and current interventions and plans. The involvement of the case manager with the families was seen as a very positive process, both by the families and the staff. Families appreciated being able to speak with the case manager by telephone or in person. Also, the families were told that if there were any changes in the resident's condition, they would be telephoned immediately. A telephone number where the case manager could be reached during identified hours was given to the families. They were encouraged to use the telephone number or visit the case manager. Family involvement with the case manager allowed the nursing staff additional time for direct care of the resident. Time they had previously spent on the telephone or talking with families now was being spent on resident care and assessment.

The case manager also attended all of the interdisciplinary team conferences held for any resident being followed for CHF. Residents, as well as their families, were encouraged by members of all disciplines to attend meetings and provide input on the resident's plan of care. This involvement gave the case manager the opportunity to educate residents, their families, and members of other disciplines on the disease process and to encourage all involved to assist residents in achieving their highest possible levels of functioning.


The introduction of the case management model to the interdisciplinary team has proved to be of great benefit to residents and their families. Both groups have voiced to the staff and at team conferences their increased satisfaction with care. Readmissions to acutecare facilities of residents diagnosed with CHF in the first 8 months of 1998 have decreased by 50%. Mortality rates have decreased in the same time period by 60% for residents with a diagnosis of CHF.

Discussions between the case manager and the health care director encouraged the health care staff to participate more actively in the planning of resident care. As documentation has improved with increased focus, the members of the health care staff have become more motivated to discuss health care regimens and planned outcomes of the residents with individuals from all involved disciplines.

The assessment will be added to the residents' charts, along with the nurses' clinical assessment. These forms will include the resident goals, plans, interventions, and evaluations for each discipline.


The interdisciplinary team already has identified the need to review the initial data. A formal, written questionnaire is being developed by the interdisciplinary team to be completed by residents and their families who are followed by the case manager. Its purpose is to request input and suggestions related to the case management process.

Variables for all residents with a diagnosis of CHF are being considered for their impact on outcome. These variables include age, when the resident was first diagnosed, other health problems, and medication regimens. All data collected at this facility in the future will include these variables.

Clinical indicators are being developed by nursing staff for future evaluation. These indicators will provide a consistent framework for collecting data that can be used to measure quality of resident care and systems of care with the case management model. A task force of volunteers from nursing staff meets weekly to develop the clinical indicators.

The case management model was used by nurses in the first phase of implementation. The benefit of case management was identified quickly by the entire interdisciplinary team. Residents, as well as their families, benefited by greater input and decision-making. The case manager encouraged input from each team member, thereby encouraging collaboration among all team members. The interdisciplinary team also sought suggestions from the quality assurance manager related to the collection of data and ways in which the results of the data collection process can define care in the future.

The development and implementation of case management has been a growing and ongoing process. Initially, the team had discussed the development and implementation of the case management model as a task that would be developed, completed, implemented, and evaluated. Recently, the interdisciplinary team added another step - ongoing. As one member of the team stated, "We are only the beginning."


  • Aronow, W.S. (1996). Therapy of congestive heart failure in older patients. Nursing Home Medicine, 4(2), 61-66.
  • Dente-Cassidy, A.M., McVan, B., Mason, J., & Nornhold. P. (Eds.). (1993). Caring for the patient with congestive heart failure (Educational Monograph January). Brick, NJ: Bristol-Myers Squibb Co. & the Nursing Institute.
  • Haddock, K.S., Johnson, RK., Cavanaugh, J., & Stewart, G.S. (1997). Oncology case management, linking structure and process with clinical and financial outcomes. Nursing Case Management, 2(2), 44-48.
  • Hoole, A., Greenburg, R., & Pichard, C. (1988). Patient care guidelines for nurse practitioners (3rd ed.). Boston: Little Brown.
  • Leshem, O., & Varholak, D. (1996). Longterm care nursing standards, policies and procedures. Hebrew Home and Hospital, Center, for Gerontological Nursing. Gaithersburg, MD: Aspen.
  • Matteson, M.S., & McConncll, E.S. (1988). Gerontological nursing, concepts and practice. In I. Rader (Ed.), Gerontological nursing in acute care setting (pp. 722-759). Philadelphia: Saunders.
  • Tahan, H.S. (1996). A ten step process to develop case management plans. Nursing Case Management, 1(3), 112-121.
  • Yockey, P.S., Bobier, S.L., Harvey, G., & Spooner, S.H. (1997). Complementary nursing: An acute care case management model. Pan 1: Development and implementation. Nursing Case Management, 2(5), 183-191.


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