Journal of Psychosocial Nursing and Mental Health Services

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EDITORIAL: Views and Opinions 

Hospital Case Management for Psychiatric Diagnoses: Focusing on Quality and Cost Outcomes

George Byron Smith, MSN, RN, CCM

Abstract

Health care cost continues to skyrocket out of control. Unless health care is reformed, health care expenditures are expected to increase by 12% to 15% annually during the next 5 years. Hospital expenditures have outpaced overall health care spending by 12%. Acutecare mental health services comprise a large percentage of our health care costs. Studies have shown that one in five Americans have a psychiatric disorder and that one in three will experience mental illness at some point in his or her lifetime. The current health care reform is an attempt by government and consumers to control health care costs. Health care providers can no longer "hide their heads in the sand" regarding cost. We are accountable to our clients to provide care that is cognizant of both quality and cost outcomes.

Consumers of mental health care are demanding more cost-effective and efficient treatments while continually expecting high-quality patient care with optimal outcomes. With the decrease in community funding and resources, the failure of deinstitutionalization policies, and inadequate public and private insurance for mental health services, there is an increase in acuity levels of psychiatric patients seen in the acutecare hospital setting. Psychiatric nurses are managing sicker patients directly on the nursing units with shorter time frames to provide care and manage symptoms. These patients require more laborintensive nursing care, produce higher costs in treatments and medications, and use larger amounts of hospital resources. Nurses and hospitals are developing new systems to meet these needs and to use resources in a more costeffective manner. The current health care crisis and reform movement have prompted health care organizations to explore and implement systems that enhance quality patient care while also promoting cost-effective resource use.

Case management is a strategy that focuses on the problems and needs of patients/clients and their families and friends, while maintaining a balance among process, outcome, and cost. The overall purpose of case management is to advocate for the patient through coordination of care, which results in reduced fragmentation, and ultimately, cost. Case management is a system that focuses on achievement of desirable patient outcomes, appropriate lengths of stay, efficient use of resources, and patient involvement and satisfaction.

Case management has become an exciting option and opportunity for acutecare hospitals. Hospital case management allows an institution to simultaneously control quality and contain cost of providing care. The goal of hospital case management is to standardize patient care by diagnosis to ensure patients receive consistent and appropriate care. In addition, case management allows health care providers to document treatment effectiveness and outcomes. In case management, the patient's care is managed and coordinated by an individual or group of individuals. This individual, or case manager, is held accountable for quality and cost outcomes in patient treatment.

In addition, hospital case management promotes and fosters collaborative practice among physicians, nurses, and support services. Physicians, nurses, and staff have an increased opportunity to formally and informally meet to discuss planning and progress of each patient care. Each discipline historically has developed individual plans of care for each patient (ie. the nursing care plan, physician's plan of care, physical therapy's plan of care). However, these plans usually are separated in the medical record with little to no communication or input among disciplines. At times these plans, goals, and outcomes have contradicted one another, causing disciplines to work against themselves.

Case management merges the different plans into one collaborative plan with mutually agreed upon goals and outcomes. Each discipline is aware of the others interventions, how these interventions may affect one another, and the progress of the patient. Those of us who work…

Health care cost continues to skyrocket out of control. Unless health care is reformed, health care expenditures are expected to increase by 12% to 15% annually during the next 5 years. Hospital expenditures have outpaced overall health care spending by 12%. Acutecare mental health services comprise a large percentage of our health care costs. Studies have shown that one in five Americans have a psychiatric disorder and that one in three will experience mental illness at some point in his or her lifetime. The current health care reform is an attempt by government and consumers to control health care costs. Health care providers can no longer "hide their heads in the sand" regarding cost. We are accountable to our clients to provide care that is cognizant of both quality and cost outcomes.

Consumers of mental health care are demanding more cost-effective and efficient treatments while continually expecting high-quality patient care with optimal outcomes. With the decrease in community funding and resources, the failure of deinstitutionalization policies, and inadequate public and private insurance for mental health services, there is an increase in acuity levels of psychiatric patients seen in the acutecare hospital setting. Psychiatric nurses are managing sicker patients directly on the nursing units with shorter time frames to provide care and manage symptoms. These patients require more laborintensive nursing care, produce higher costs in treatments and medications, and use larger amounts of hospital resources. Nurses and hospitals are developing new systems to meet these needs and to use resources in a more costeffective manner. The current health care crisis and reform movement have prompted health care organizations to explore and implement systems that enhance quality patient care while also promoting cost-effective resource use.

Case management is a strategy that focuses on the problems and needs of patients/clients and their families and friends, while maintaining a balance among process, outcome, and cost. The overall purpose of case management is to advocate for the patient through coordination of care, which results in reduced fragmentation, and ultimately, cost. Case management is a system that focuses on achievement of desirable patient outcomes, appropriate lengths of stay, efficient use of resources, and patient involvement and satisfaction.

Case management has become an exciting option and opportunity for acutecare hospitals. Hospital case management allows an institution to simultaneously control quality and contain cost of providing care. The goal of hospital case management is to standardize patient care by diagnosis to ensure patients receive consistent and appropriate care. In addition, case management allows health care providers to document treatment effectiveness and outcomes. In case management, the patient's care is managed and coordinated by an individual or group of individuals. This individual, or case manager, is held accountable for quality and cost outcomes in patient treatment.

In addition, hospital case management promotes and fosters collaborative practice among physicians, nurses, and support services. Physicians, nurses, and staff have an increased opportunity to formally and informally meet to discuss planning and progress of each patient care. Each discipline historically has developed individual plans of care for each patient (ie. the nursing care plan, physician's plan of care, physical therapy's plan of care). However, these plans usually are separated in the medical record with little to no communication or input among disciplines. At times these plans, goals, and outcomes have contradicted one another, causing disciplines to work against themselves.

Case management merges the different plans into one collaborative plan with mutually agreed upon goals and outcomes. Each discipline is aware of the others interventions, how these interventions may affect one another, and the progress of the patient. Those of us who work in psychiatry have made progress through treatment plans when providing team-oriented care to patients; however, we continue to foster barriers among disciplines and inadequate communication about expected treatment outcomes and means to achieve those outcomes. Case management takes treatment planning one step further by making a practitioner responsible for the entire patient's care.

Studies have documented that lack of patient involvement has resulted in poor post-hospitalization compliance. Hospital case management actively involves the patient in his or her care by informing the patient and family of the expected health promotion and patient education. Hospital case management fosters patient, family, and practitioner satisfaction by ensuring all patients will receive appropriate and consistent patient education and care.

Case management has been actively pursued by acute-care hospitals for medical and surgical diagnoses. Many believed case management and standardized care was not possible for psychiatric populations due to psychiatric patients' unique and varying needs. However, a closer examination of the care for psychiatric patients, from admission to discharge, has demonstrated that a patient's progression can be mapped out in a systematic plan of care. By focusing on the target symptoms and critical interventions determined to be necessary for a specific diagnosis, a standardized plan of care with expected outcomes to stabilize acute symptoms is achievable.

The standardized plan of care contains protocols for managing the care of the patient. The care is managed by tools called "critical pathways," which are generally divided into the number of days a patient is expected to stay in the hospital. Each day is then subdivided into certain processes or incidents that must occur in a specified timeframe to achieve the appropriate length of stay and expected outcomes. Those key processes may be categorized according to consultants, psychological testing, activities, treatments, medications, diet, diagnostic studies, groups, individual therapy, discharge planning, and patient/family education.

Case management is a win/win strategy for patients and health care providers. Case management and critical pathways, when effectively planned, implemented, communicated, and evaluated, will result in positive benefits for physicians, nurses, administrators, hospitals, and patients. According to the literature and research, patient care and outcomes have been demonstrated to improve in a case management system. Case management offers the following advantages for psychiatric diagnoses in an acute-care setting:

* Decreases fragmentation;

* Increases access to services;

* Streamlines care and resources;

* Improves patient and family education;

* Standardizes plan of care;

* Promotes collaboration;

* Improves communication;

* Decreases readmission rates;

* Involves patient and family in care;

* Increases awareness of financial and quality implications of providing health care; and

* Effectively measures quality and cost outcomes.

Psychiatric nurses and mental health care professionals should learn and develop the knowledge and skills to implement case management. A case management system provides care in a cost-effective manner while maintaining the quality of patient care. Health care providers and their staffs will continue to be asked to do more with less. The health care reform movement will require health care professionals to become more creative in providing high-quality patient care with less resources. With case management, acute-care psychiatric settings will be prepared to meet the health care needs of our patients and document costeffective quality care with me best outcomes.

10.3928/0279-3695-19940201-02

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