Patient Care Management 1 and 2

PATIENT CARE
MANAGEMENT &
NURSING
ADMINISTRATION
Cyruz P. Tuppal, PhDNS, DMS, MSN, MASPED, MHA, MBA, MSc, PGDipRDM, RN, RM, LPT
+639083007876
drcyruz@gmail.com
TRENDS IN
HEALTHCARE
TRENDS IN HEALTHCARE
HIGH-VALUE CARE
The CCM model is a team-driven model

that’s designed to provide care for a defined
segment of patients like pediatrics or
geriatrics. Its clinical decision making is
marked by systematic reports that drive
Collaborative Care Model (CCM) measurable disease outcomes, and it also
uses evidence to allow teams to aim for
improved health outcomes using
scientifically proven treatments
HIGH-VALUE CARE
The key characteristics of the patient-centered medical home

include comprehensive care, where patients receive care for
physical health, mental health, disease prevention, wellness,
and acute and chronic conditions. The model is also patient-
Patient-Centered centered, as each healthcare practitioner partners with the
patient and their family and makes an effort to understand
Medical Home and respect the patient’s unique culture, needs, values, and
preferences. Coordinated care accessible services and a
commitment to quality and safety are also key metrics to the
patient-centered medical home model.
HIGH-VALUE CARE
A key metric in the independence at home

model is a demonstration of greater
accountability as healthcare providers spend
more time with their patients and therefore
Independence at carry greater responsibility for the patient’s
care. The model also focuses on timely and
Home appropriate care, as well as insuring care-
team leadership provided by a physician or
an NP.
TECHNOLOGY TAKEOVER
Blockchain technology’s capacity to generate complete

transaction histories would curtail Medicare fraud, an
issue that’s costs an estimated $30 billion over the last 20
years. Its decentralized nature would also offer a new
Blockchain approach to security, as its data is traceable and
unalterable. Blockchain tech could also drive a smart
Opportunities in payment system, which would help make claims
processing more efficient. Additionally, it could improve
Healthcare healthcare providers’ capacity to have timely access to
electronic health records, leading to better patient
treatment.
TECHNOLOGY TAKEOVER
A dedication to analyzing patient data

will lead to improvements in population
health. It’s also driven by the belief that
critical decisions affecting treatment
Patient Data should be based on reliable, real-time
Analytics data. In order to bring fairness to
healthcare, transparency in inpatient data
is also vital.
TECHNOLOGY TAKEOVER
Studies show that 88% of consumers are willing to share

data derived from AI-infused “wearables” with
healthcare professionals. AI could be a valuable tool for
physicians and nurses, as deploying smart machines to
amplify their natural abilities, performance, and quality
Artificial Intelligence will be improved. AI is not an intimidating concept to
patients, as two in three individuals would use AI-based
after-hours services. Robots could also provide caregiver
relief by reminding patients to take medication and
leading patients through exercises.
PRECISION MEDICINE
Precision medicine can help reduce acute hospital

admissions resulting from medication side-effects
and adverse reactions. This can also lead to
Precision medicine is an innovative shifting treatment from conditions to predictive
approach that takes into consideration and preventative care. Additionally, precision
individual differences in people’s medicine can use data to spot prescription
inefficiencies. It can be used to study how genes
genes, environments, and lifestyles.
affect a person’s response to particular drugs, as
well.
HEALTH CARE
AROUND THE GLOBE
HEALTH CARE AROUND THE
GLOBE
THE HEALTH CARE CHALLENGE: Services for those with need and in need (WHO, 2008)
INVERSE CARE  Public spending on health services most often benefits the rich more than the poor
in high- and low-income countries alike.
IMPOVERISHING  Over 100 million people annually fall into poverty because they must pay for
health care.
CARE
FRAGMENTED AND  Excessive specialization of health-care providers and the narrow focus of many
disease control programs discourage a holistic approach to the individuals and the
FRAGMENTING CARE families.
UNSAFE CARE  Poor system design that is unable to ensure safety and hygiene standards leads to
high rates of hospital-acquired infections, medication errors and other avoidable
adverse effects cause of death and ill-health.
MISDIRECTED CARE  Neglecting the potential of primary prevention and health promotion to prevent
up to 70% of the disease burden.
11
PATIENT CARE MANAGEMENT
AS A GLOBAL CONCERN
Effective patient care management must be thoughtfully designed and based on principles
PRINCIPLES RATIONALE
 Learn as much about the usual trajectory of  This allows to assess whether an individual patient’s course is as
the disease or condition as possible. expected or whether it is deviating from the norm.
 Anchor patient care management practices  Provide milestones against which to evaluate the effectiveness of the
to outcomes and critical indicators. practice for individual patients as well as populations.
 Patterns and trends are important.  Individual patient’s patterns allows a clinician to anticipate problems
and be proactive.
 Patterns of a population sets the stage for creating systems and
strategies to better manage the issues and problems presented by the
patients within the group.
AS A GLOBAL CONCERN
 Establish roles, tools, and systems that  Case management and clinical paths are 2 examples of this that have
support patient care management. demonstrated effectiveness in optimizing clinical as well as financial
outcomes.
 Patient care management at the unit  A centralized care management approach involves a role such as a patient
or area level can be centralized or care coordinator who is responsible for managing the care of a group of
decentralized patients.
 The most common decentralized approach to patient
 care management is primary nursing in which a specific nurse works with
peers and assistants and is accountable For the outcomes of individual
patients’ care within the context of a single area
AS A GLOBAL CONCERN
 Teaching patients and their  This is an issue that spans care sites and levels and must be carefully
community caregivers how to manage designed. At the acute care level (hospital-based care, urgent care, and
their health and their illness emergency department are), the focus is primarily on survival as
conditions is a cornerstone to effective compared to episode and continuum dimensions
care management.
 There is a shift in roles as the work of  Expanded skills in coaching, educating, and mentoring are core for
nurses and other clinicians extends clinicians in this arena.
from a shift/visit or unit/site focus to
episode and continuum-focused
interactions.
AS A GLOBAL CONCERN
 Negotiation and political savvy are important  Represents the synergy of a number of skills and attributes of the
components of a clinician’s skill set, clinician, such as courage, deep knowledge of the pathophysiology
particularly when patient care management is of the disease, and creativity.
considered.
 Topic of noncompliance or nonadherence  An individual’s level of adherence to a therapeutic regimen is a
must be addressed complex interaction of a number of factors ( knowledge (about the
disease process and the treatment regimen), economics, social
support, culture, religious beliefs and practices, values, cognition,
emotional state
AS A GLOBAL CONCERN
 Knowledge of community (and other)  Effective patient care management involves identifying resources
resources is important. (such as support groups, Area Council on Aging, the American
Cancer Society, homeless shelters, etc.) in the community.
CARE MANAGEMENT
Care management is a set of activities

intended to improve patient care and
These efforts have demonstrated
reduce the need for medical services by
potential to improve quality and control
enhancing coordination of care,
costs for patients with complex
eliminate duplication, and helping
conditions.
patients and caregivers more effectively
manage health conditions.
CARE MANAGEMENT
Successful care
Care management programs
management programs
Care management improves tergeting the hospital-to-
include specially trained
quality, but it may take time home transition were the
nurse care managers, in-
to see results. most successful in reducing
person encouners and
costs.
physician involvement.
Payment reform may

improve the success of care
management programs and
provide incentives to
implement them.
CARE MANAGEMENT
Offering care management to

patients who are not expected to
Similarly, care management for
Care management is relatively be high utilizers of hospital,
patients too sick to benefit is
costly. specialty and emergency
ineffective.
department care would not
reduce costs.
CARE MANAGEMENT
Care management is a promising

team-based, patient-centered
It also encompasses those care
approach “designed to assist
coordination activities needed to
patients and their support
help manage chronic illness.
systems in managing medical
conditions more effectively.”
CARE MANAGEMENT
KEYS TO SUCCESSFUL CARE MANAGEMENT
In-person encounters: Person-to-
Training and personnel: Programs with
person encounters, including home
specially trained care managers who Physician involvement: Placing care
visits, are necessary features of
have a relatively low workload are managers with physicians in primary
effective care management. Care
most successful. Most care managers care practices may help facilitate
management relying solely on
are registered nurses (RNs) who work physician involvement.
telephone encounters has not shown
as part of a multidisciplinary team.
success.
Informal caregivers: Patients with

complex health care needs, particularly
Coaching: Coaching involves teaching
those with physical or cognitive
patients and their caregivers how to
functional decline, often need the
recognize early warning signs of
assistance of informal caregivers to
worsening disease.
actively participate in care
management.
CARE MANAGEMENT
IMPROVE QUALITY AND REDUCE COSTS
Most care management findings are from

Costs and quality outcomes are interrelated. research-based programs. Research-based
Patients who are experiencing poor quality programs are generally well-funded, with There is strong research evidence that care
outcomes often require more hospitalizations specially trained care managers whose management improves quality, but the effect
and emergency department visits. For this services are supported by grant funds. There on cost reduction is less consistent. Hospital-
reason, utilization of high-cost services can are many examples of care management in to-home care management programs have had
be viewed as one marker of inadequate real-world treatment settings, but they the most success in reducing costs.
quality of care. generally do not have a strong evaluation
component.
CARE MANAGEMENT
Commercial disease management

Care management in primary care
vendors have provided data
improves quality, but research
demonstrating success, but
indicates it may take time to see
methodological issues call into
results. Quality was measured by
question these findings. The evidence
improvement in functional ability,
demonstrating quality improvement is
mortality, bed disability days, and
stronger than the evidence on cost
overall quality of life.
reduction
CARE MANAGEMENT
The most effective care management Home-based care management programs

Care management within integrated
programs are those targeting patients have failed to demonstrate improved
multispecialty groups improves quality
discharged from hospitals. Studies found quality or lower costs. Two systemic
but does not consistently reduce costs.
that care management programs targeting reviews did not find improvements in
The only study that showed a reduction in
the hospital-to-home transition have mortality, health status or service use for
hospitalizations involved the use of
reduced hospital readmissions and patients enrolled in home-based care
geriatricians.
lowered costs. management programs
CARE MANAGEMENT
ROLE DO PAYMENT POLICIES PLAY IN
CARE MANAGEMENT
Care management programs that

Fee-for-service payment have had success outside of Patients with complex health
policies do not support the research settings are care needs represent a small but
adoption of care management concentrated in organizations growing sector of the
programs. that do not use fee-for-service population.
payments.
CARE MANAGEMENT
POLICY IMPLICATIONS
Payment reform may Absent a broad scale

Current Medicare payment
improve the success of care payment reform, a separate
policies provide a
management programs and reimbursement could be
disincentive to reduce
provide incentives to created for RN care
hospital readmissions.
implement them. managers.
A system that enrolls or assigns patients

to interventions across the continuum of
health and illness. It includes wellness
exams and routine screenings, utilization
reviews, event focus, short-term case
management, and the management of
long-term chronic conditions.
KEY CARE MANAGEMENT STRATEGIES
Providers must be able to identify

Modifiable risk factors are those that an
populations with modifiable risks if they
Identify Populations individual has control over and, if
minimized, will increase the probability
are to manage and coordinate care in
with Modifiable Risks that a person will live a long and
ways that help achieve the goals of cost
savings, improved quality, and enhanced
productive life
patient experience.
Careful management of select Patient characteristics such as ethnicity,

populations may increase the quality of In the broadest terms, modifying risk age, metabolic risk factors, smoking
care (e.g., improving the delivery of includes improving health outcomes, status, and chronic disease burden, as
appropriate clinical preventive services), positively influencing psychosocial well as psychosocial issues, such as
safety (e.g., medication reconciliation to concerns, as well as helping patients availability of caregiver support, help
avoid duplication and prescription achieve goals that produce better health practices, and payors identify individuals
errors), and efficiency (e.g., reducing outcomes. and populations that might benefit from
unnecessary utilization). CM services.
Coordination of Care.
Coordination of specialty referrals, Self-Management Support. Self-
Align Care Management assistance with ancillary services, management support is particularly
Services to the Needs of the and referrals to and coordination important for patients dealing with
Population with community services, also chronic diseases and those with
support high-risk and/or high-cost emerging modifiable risks.
populations.
Outreach. Outreach to patients is a

critical service for managing
patients with chronic conditions and
those experiencing transitions of
care.
Once patients’ needs for CM services have been

determined, practices must decide how best to
Identify and Train Personnel Appropriate to the assign staff to deliver those services. Two
Needed CM Services approaches should be considered: (1) assigning or
hiring a dedicated care manager or (2) distributing
CM functions across two or more clinic personnel.
AND RECOMMENDATIONS
Strategy Recommendations for Medical Recommendations for Health Recommendations for Health
Practice Policy Services Research
 Identify populations  Use multiple metrics to identify  Consider return on investment  Determine the benefits to
with modifiable risks patients with modifiable risks of providing CM services to different patient segments
 Develop risk-based approaches to patients with a broad set of from CM services
identify patients most in need of care eligibility requirements  Investigate the understanding
management (CM) services  Establish metrics to identify of and parameters affecting
and track CM outcomes to modifiable risks.
determine success  Develop/refine tools for risk
 Implement value-based stratification
payment methodologies  Develop predictive models to
through State and Federal tax support risk stratification
incentives to practices for
achieving the triple aim
KEY CARE MANAGEMENT
STRATEGIES AND
RECOMMENDATIONS
Strategy Recommendations for Recommendations for Recommendations for
Medical Practice Health Policy Health Services Research
 Identify populations with  Use multiple metrics to  Consider return on  Determine the benefits to
modifiable risks identify patients with investment of providing different patient segments
modifiable risks CM services to patients from CM services
 Develop risk-based with a broad set of  Investigate the
approaches to identify eligibility requirements understanding of and
patients most in need of  Establish metrics to parameters affecting
care management (CM) identify and track CM modifiable risks.
services outcomes to determine  Develop/refine tools for
success risk stratification
 Implement value-based  Develop predictive models
payment methodologies to support risk
through State and Federal stratification
tax incentives to practices
for achieving the triple
aim
KEY CARE MANAGEMENT
STRATEGIES AND
RECOMMENDATIONS
Strategy Recommendations for Medical Recommendations for Health Recommendations for Health
Practice Policy Services Research
 Identify and train personnel  Determine who should provide  Incentivize care manager  Determine what teambuilding
appropriate to the needed CM CM services given population training through loans or activities best support delivery
services needs and practice context tuition subsidies of CM services
 Identify needed skills,  Develop CM certification  Design protocols for workflow
appropriate training, and programs that recognize that accommodate CM services
licensure requirements functional expertise in different contexts
 Implement interprofessional  Develop models for
team-based approaches to care interprofessional education
that bridge trainees at all levels
and practicing health care
professionals
CARE MANAGENENT:
FUTURE DIRECTION
There is still much to learn about the By practices working diligently to

effective implementation of CM. implement CM and policymakers
Research is needed to discover which supporting their efforts through
CM services are most effective, the changes in payment models and
contexts in which they are ideally incentives for achieving the triple aim,
deployed, and how they are best improved management of the health of
executed. populations will be possible.
CARE MANAGEMENT
VERSUS CASE
MANAGEMENT
CARE MANAGEMENT CASE MANAGEMENT
Background of  Diverse – Social work, nursing, psychology,  Social workers and nurses primarily (with some
professional gerontology, other health related fields mental health counselors)
Employed  Primarily private for profit (some nonprofits)  Agency/organization: insurance company,
hospital, community mental health, etc.
 Government: Medicaid program, housing
authority, adult/children’s protective services,
veterans’ programs, etc.
Limits  Client defines the scope of work (based on a  Agency defines the limits/scope of work.
care plan that is developed with the client’s Typically will be managing a specific disease,
input) issue, condition or event, and focus may be
constrained by regulations, policies and funders
CARE MANAGEMENT
VERSUS CASE
MANAGEMENT
CARE MANAGEMENT CASE MANAGEMENT
Focus  Holistic, client/family centered approach  Client/patient centered but also considers
 Understanding underlying client/family dynamics medical/legal/financial issues that can involve
 Advocating for client needs & the client’s maximum stakeholders
benefits (i.e., from an insurer)  Eliminating non-compliance and over-utilization
Stakeholder  Client  Can be a funding source (i.e., insurance
company, entitlement, hospital, etc.)
Payment  Client pays cost (occasionally some reimbursement  Agency specific funding (hospital system,
from long-term care insurance but this is not typical) insurance company, government program, for
example)
Goal  Promote better quality of life, maintain independence  Improve health status, cost effective outcomes
to the extent possible, improve communication among and efficiencies, reduce overutilization of
those involved in client’s care, ensure client’s needs services
are met and client’s goals are achieved, provide
education to client and family members
PATIENT CARE
MANAGEMENT:
COMPREHENSIVE HEALTH
CARE
PATIENT CARE MANAGEMENT:
COMPREHENSIVE HEALTH CARE
Dimension of analysis Definition
Access to health care services This dimension crosscuts all health care practices, and involves aspects related to practice (technical) and the
organization of care, as well as political, economic, social and symbolic aspects, from access at the entrance to exit from
the health care network
Embracement This involves establishing relationships with the model of health care and quality of services, and accountability as
product and producer of care. After all, health care professionals who actively coparticipate in the health problems of
people, listen and talk, establish accountability in two ways, providing care - and inexorably establish embracement and
vice versa
Bonding Bonding enables exchange of knowledge between the technical and the popular, the scientific and empirical, the
objective and subjective, converging them to perform therapeutic acts shaped by the subtleties of each public and person,
delineating other meanings for comprehensive health care
Lines of care Organization of production processes of care in the network from various fields of knowledge and practice, at the
individual and collective level, in the construction of a comprehensive and effective health care model.
Accountability Accountability in the act of caring for people, in a movement aimed at expanding the therapeutic act, valuing the
uniqueness of each service user, in a manner that is shared among staff, users, families and managers of the system.
Responsiveness Responsiveness to demands according to individual and collective needs, whether at the entrance or other levels of the
system.
THE HEALTH SERVICES SYSTEM: COMPREHENSIVENESS
CAPACITY Range of services
Provision
of Problem recognition
care
PERFORMANCE
Receipt of
care
HEALTH STATUS
(outcome)
Source: Starfield. Primary Care: Balancing Health Needs, Services,

and Technology. Oxford U. Press, 1998.
PATIENT CARE
MANAGEMENT: PRIMARY
HEALTH CARE
PRIMARY CARE ORIENTED HEALTH SERVICES
Personnel
Facilities and equipment
Range of services
Organization Community resources
CAPACITY Management and amenities
Continuity/information systems
Knowledge base
Accessibility
Financing
Population eligible
Provision Governance Cultural and
of care behavioral
Problem recognition
Diagnosis
characteristics
Management
PERFORMANCE Reassessment
Receipt
Person-focused relationship
of care Utilization
Acceptance and satisfaction
Social, political,
Understanding economic, and
Participation physical
environments
HEALTH STATUS Longevity
(outcome) Comfort
Perceived well-being
Biologic endowment Disease
and prior health Achievement
Risks
Source: Starfield. Primary Care: Balancing Health Needs, Services, and
Resilience
Technology. Oxford U. Press, 1998.
PATIENT CARE
MANAGEMENT: PATIENT-
CENTERED CARE
PATIENT-CENTERED CARE
PHC is essential health care that is a socially
appropriate, universally accessible, scientifically
The Institute of Medicine defines patient-
sound first level care provided by a suitably
centered care as “Providing care that is trained workforce supported by integrated referral
respectful of, and responsive to, individual patient systems and in a way that gives priority to those
preferences, needs and values, and ensuring that most in need, maximizes community and
patient values guide all clinical decisions.” individual self-reliance and participation and
involves collaboration with other sectors.
Health Illness Community

Care of the sick Advocacy
promotion prevention development
Social equity
Nation-wide coverage
PHC based on the
following Self-reliance
principles :
Inter-sectoral coordination
People’s involvement in the planning

and implementation of health
programs
Appropriateness
Availability
Adequacy
Accessibility
Acceptability
Basic Affordability
Requirements for Appropriateness
Sound PHC Availability
Adequacy
Accessibility
Acceptability
Affordability
The commitment to global improvements

in health, especially for the most
Primary health care (PHC) became a core
disadvantaged populations, was renewed
policy for the World Health Organization
in 1998 by the World Health Assembly.
with the Alma-Ata Declaration in 1978
This led to the ‘Health-for-All for the
and the ‘Health-for-All by the Year 2000’
twenty-first Century’ policy and program,
Program.
within which the commitment to PHC
development is restated.
The health system’s mission, Care is collaborative, coordinated,
Elements of effective patient- vision, values, leadership, and and accessible. The right care is Care focuses on physical comfort
centered care plans quality-improvement drivers are provided at the right time and the as well as emotional well-being.
aligned to patient-centered goals. right place.
Patient and family preferences, Patients and their families are an Information is shared fully and in a
The presence of family members in
values, cultural traditions, and expected part of the care team and timely manner so that patients and
the care setting is encouraged and
socioeconomic conditions are play a role in decisions at the their family members can make
facilitated.
respected. patient and system level. informed decisions.
PATIENT CARE
MANAGEMENT:
PROGRESSIVE PATIENT
CARE
PROGRESSIVE PATIENT CARE
The practical
administrating of a
Interests of the
hospital can be Cost
Public
based on five
premises:
Institutional
perpetuation for the
Quality Human Relations
sake of the
institution
Right patient, in the
Better care through right bed with the
better organization. right services at
right time.
Progressive Patient
Care
For the patient For the physician For the nurse For the hospital
Giving care
according to need
The concept of progressive patient care
is one where the focus is on the setting
Progressive patient care may be defined The patients are grouped according to
up and organizing of all the facilities,
simply as a systematic classification and the degree of their illness and the degree
staff and services within the hospital so
segregation of patients based on their of need necessary for their adequate
that they relate directly to the medical
medical and nursing needs. care.
and nursing needs of the admitted
patient.
Progressive Patient
Care
Intensive care Intermediate Care Self-Care Long-term Care
Giving care
according to need
Progressive Patient
Care
Intensive care Intermediate Care Self-Care Long-term Care Home Care
Giving care
according to need
Ambulatory
Care
Generalized Specialized
Type of ICU
ICU ICU
Progressive Patient
Care
Giving care
according to need
Ambulatory
Care
A large number of
May also have It accommodates patients are
For Moderately ill
patients 60 – 70% of total admitted and
Patients or
transferred from hospitalized discharged
Palliative Care.
ICU. patients. directly from this
unit.
Progressive Patient
Care
Giving care
according to need
Ambulatory
Care
Primarily for
For Ambulant More of Home diagnostic radiotherapy) or Helps in easy
Supervisory or
and Self- Like procedures, preparation for transition of Home
Health
Sufficient Environment as special major surgery Patient between environment.
Education
Patients. patients for treatments (like are admitted. Hospital &
Purpose.
Progressive Patient
Care
Giving care
according to need
Ambulatory
Care
For Restorative When care is

or required for a
Rehabilitative Prolonged
care. Period
Progressive Patient
Care
Giving care
according to need
Ambulatory
Care
Care of the
ambulatory patient
requiring diagnostic,
General Outpatient Referred Outpatient Emergency Outpatie
curative, preventive
and rehabilitative
services
Steps for Introduction of
Familiarity with the PPC Development of Teamwork Evaluation of Needs Orient Staff
PPC
Estimation of Costs Formulation of Policies Provide Flexibility Adequate Staffing Instruct Patients
Inform or Communicate
Public
PATIENT CARE
MANAGEMENT: CRITICAL
PATHWAYS
CRITICAL PATHWAYS
CQI, which focuses on processes and

systems to improve the efficiency and
Continuous Quality Improvement (CQI) or
effectiveness of service delivery, is a
Total Quality Management (TQM) was
methodology designed to improve quality
adopted by many health care organizations
by reducing variance, therefore eliminating
(providers, purchasers, and insurers alike).
inefficiency, rework and waste, and
reducing cost.
CRITICAL PATHWAYS
The Critical Path Method (CPM)
was originally developed in the
1950s as a tool for project planning
in industrial engineering and
managerial sciences. It has been
used extensively with great success
for projects as diverse as
construction, civil engineering, town
planning, marketing, ship building,
product design, and equipment
installation
CRITICAL PATHWAYS
Karen Zander (who developed the

CareMap System) began reporting on
CPM’s first application in the health the clinical application of CPM in the
care arena was for administrative health care literature in the mid 1980s,
planning projects. following her use of the methodology to
review patient care delivery at the New
England Medical Center in Boston
http://caremap.health/
DEVELOPING CRITICAL PATHWAYS
CareMap system
includes six CareMap tools Variance analysis Communication
components:
Health care team

Case consultation CQI
meetings
Consider what can

Determine patient problems
realistically be accomplished Discuss how the patient will
and outcomes related to the
within a given length of stay progress through a
diagnosis, including
and what needs to be included hospitalization;
intermediate outcomes;
in a discharge plan;
Determine interventions
necessary to achieve the Decide which time units (e.g.,
Discuss the daily goals to be established outcomes and Hour, day, week) to use in
met within the expected LOS; format them according to specifying the interventions
consults, diagnostic studies, and outcomes.
and so forth;
Provide a
Decrease fragmentation
Accommodate managed Improve patient/family Operationalize CQI at Enhance collaboration database(through
of service and increase
care contracts. satisfaction. the patient care level. between disciplines. variance) for CQI
access to services.
efforts.
Improve patient/family
Link actual costs to care Decrease the length of Restructure Conform to 1994
participation and Conduct action research.
given. stay when appropriate. accountability models. JCAHO requirements.
education.
Develop accurate
Develop realistic Prepare for Achieve more legal
Streamline models of resource,
Decrease readmissions. outcomes management computerization of protection with
documentation. staffing, and materials
approaches. medical records. CareMaps.
management needs.
With a large volume
When deciding on which parameters
to base a clinical pathway, Zander
suggests selecting a patient
That is problematic in cost and/or quality data
With a perceived opportunity to improve efficiency and effectiveness of medical and hospital
population:
staff interventions
With applicability of the diagnosis/procedure to a written pathway
With written standards, guidelines, and protocols available in authoritative sources
Priority of service.
Literature search— Steering group— Paperwork design—

Targeting strategy— Gaining consensus—
attend conferences, convene a committee to create a form and
decide which diagnoses enlist support from key
review books and oversee project procedure for the
to put on the path. people.
articles. implementation. critical pathway.
Pilot program— Preliminary findings— Refine the program— Full implementation—

implement on a limited gather and review the measure, adjust, and expand the critical path
scale. early data. revise program. project further
BENEFITS OF CRITICAL PATHWAYS
Standardized care from Promotion of the

Improved communication
one unit to another and professional development
among departments and
one outpatient center to and satisfaction of health
disciplines.
another. care providers.
Increased patient
Daily coordination and
satisfaction from early Less fragmentation of
evaluation of patient care
discharge planning and care.
activities.
patient/family teaching.
CRITICAL PATHWAYS
REMEMBER:
When developing a critical pathway, the team needs to search
carefully and critically for elements of “best practice” (such as a
lower incidence of postoperative nausea and vomiting associated with the use of
one medication rather than another) and “opportunities for
improvement” (such as reducing the number of needlesticks by
coordinating the timing of blood values required by pharmacists, physicians,
respiratory therapists, and so on)
PATIENT CARE
MANAGEMENT:
MEDICATION
RECONCILIATION
MEDICATION RECONCILIATION
Patients often receive new medications or have
changes made to their existing medications at
times of transitions in care—upon hospital
admission, transfer from one unit to another
during hospitalization, or discharge from the
hospital to home or another facility.
As a result, the new medication regimen

prescribed at the time of discharge may
inadvertently omit needed medications,
unnecessarily duplicate existing therapies, or
contain incorrect dosages.
Up to 67% of patients’ prescription
Around half of the medication errors that
medication histories recorded on
occur in hospital are estimated to occur
Adverse drug events (ADE) are a leading admission to hospital have one or more
on admission or discharge from a clinical
cause of injury and death within health errors and 30 – 80% of patients have a
unit or hospital4 and around 30% of
care systems around the world. discrepancy between the medicines
these errors have the potential to cause
ordered in hospital and those they were
patient harm.
taking at home.
When a patient’s transition from the

hospital to home is inadequate, the Chart reviews reveal that over half of all
repercussions can be far-reaching — hospital medication errors occur at the
hospital readmission, an adverse drug interfaces of care.
event, and even mortality.
DEFINITION & PROCESS MEDICATION
RECONCILIATION
refers to the process of avoiding such inadvertent inconsistencies across transitions in
care by reviewing the patient's complete medication regimen at the time of admission,
transfer, and discharge and comparing it with the regimen being considered for the new
setting of care.
Medication reconciliation The Joint Commission's
announcement called on
was named as 2005 National In 2006, accredited organizations
organizations to "accurately and
Patient Safety Goal #8 by the were required to
completely reconcile medications
Joint Commission. across the continuum of care."
to communicate "a complete list of the The Joint Commission

"implement a process for obtaining
and documenting a complete list of the
patient's medications to the next suspended scoring of
provider of service when a patient is medication reconciliation
patient's current medications upon the
referred or transferred to another
patient's admission to the organization
setting, service, practitioner or level of during on-site accreditation
and with the involvement of the
patient" and
care within or outside the surveys between 2009 and
organization." 2011.
PRINCIPLES OF MEDICATION RECONCILIATION
An up-to-date and accurate A formal structured process

patient medication list is for reconciling medications
Guiding Principle 1: Guiding principle 2:
essential to ensure safe should be in place cross all
prescribing in any setting. interfaces of care.
Medication reconciliation is
Medication reconciliation on
integrated into existing
admission is the foundation
Guiding principle 3: Guiding Principle 4: processes for medication
for reconciliation throughout
management and patient
the episode of care.
flow.
PRINCIPLES OF MEDICATION RECONCILIATION
The process of medication

reconciliation is one of
Guiding Principle 5: shared accountability with Guiding Principle 6:
staff aware of their roles and
responsibilities
Staff responsible for

Patients and families are
reconciling medicines are
involved in medication Guiding Principle 7:
trained to take a BPMH and
reconciliation.
reconcile medicines.
DETAILED PROCESS OF MEDICATION
RECONCILIATION
prescribed (medications the patient is instructed to take by the
prescriber)
non-prescribed (the prescriber did not advise the patient to take
is a medication history the medication)
obtained by a clinician
Step 1: Best which includes a prescription medication
Possible thorough history of all
regular medication use
Medication (prescribed and non-
non-prescription medication (e.g., over-the counter (OTC))
History prescribed), using
(BPMH) several different complementary or herbal medication)
sources of
information. recreational drugs
‘prn’ (i.e., “as needed”) medication

RECONCILIATION
community pharmacists, physicians and/or home care providers
The medication inspection of medication containers

Step 2:
information should be
Verifying and verified with more than patient medication lists
documenting
the history
one source as
appropriate. These may
government medication database
include:
previous patient health records
RECONCILIATION
discrepancies in which the

prescriber has made an
intentional choice to add,
undocumented intentional
change or stop a medication
The goal is to reconcile the but this choice is not clearly
Step 3: documented.
medications within 24 hours
Medication
of admission in order to
reconciliation at
resolve potential problems
admission discrepancies in which the
early in the process.
prescriber unintentionally
unintentional changed, added or omitted a
medication the patient was
taking prior to admission.
RECONCILIATION
RECONCILIATION
prescribed (medications the patient is instructed to take by the
prescriber)
At the end of the episode non-prescribed (the prescriber did not advise the patient to take
of care, the Best Possible the medication)
Medication Discharge
Plan (BPMDP) should prescription medication
Step 4: be communicated to the
Supply patient, community
non-prescription medication (e.g., over-the counter (OTC))
accurate pharmacy, primary care
physician, or alternative
information care facility or health complementary or herbal medication)
care team/service that
will next be providing
care to the patient. recreational drugs
‘prn’ (i.e., “as needed”) medication

RECONCILIATION
Assessing a patient’s understanding of their

Patient and
discharge medication plan can inform
family
required improvements to the discharge
involvement
medication reconciliation process.
“WHO High 5’s Assuring Medication

Education and
Accuracy at Transitions in Care: Medication
training of staff
Reconciliation Implementation Guide.”
IMPLEMENTATION STRATEGY FOR
PROCESS MANAGEMENT STRATEGY
Event Analysis –
Performance
SOP Implementation identification and
Measures –
Evaluation – self- analysis of any
quantitative
reported information adverse events
measurement of
regarding the directly associated
processes and
implementation with/related to the
outcomes associated
experience. SOP or its
with the SOP.
implementation.
PATIENT CARE
MANAGEMENT: PATIENT
CARE TEAMS
PATIENT CARE TEAMS
Providers spend 13
Most physicians only
Mounting evidence percent of their day on
deliver 55 percent of
demonstrates that a care coordination
recommended care and
team of providers with activities and only half
42 percent report not
multidimensional skill of their time on
having enough time
sets most effectively activities using their
with their patients
delivers health care. medical knowledge
(Bodenheimer, 2008).
(Loudin, et al., 2011).
PATIENT CARE TEAMS
Yarnall KSH, Pollak KI, Østbye T, et al. Primary care:

is there enough time for prevention? Am J Public
Health. 2003 Apr;93:635-64; and Østbye T, Yarnall
KSH, Krause KM, et al. Is there time for management
of patients with chronic diseases in primary care? Ann
Fam Med 2005 May;3:209-14.
PATIENT CARE TEAMS
Teams deliver comprehensive, first-contact
care and address the needs of patients and
families through a broad range of services
delivered by multidisciplinary professionals. Front desk staff can reach out to
Nurses can conduct complex care
patients who need but have not
In the team-based care model, all care team management,
received evidence-based care,
members contribute to the health of the
patients by working at the top of their
licensure and skill set.
Medical assistants (MAs) can Pharmacists can conduct

provide patient self-management medication reconciliation and
support, and management.
PATIENT CARE TEAMS
Task Who does it now? In a perfect world, who would do it?
 Book appointments  RNs and clerical  Clerical support
 Take incoming calls  Everyone  Clerical support
 Chart preparations  MAs  Clerical support
 Triage  RNs and MDs  RNs
 Medication refill requests  RN, MD, clerical  Clerical with MD signature
 Check-in  Receptionists  Receptionists
 Suture removal  MD  RN
 Dressing change  MD  MA
 Flu shots  RN  MA
Other
PATIENT CARE
MANAGEMENT: PATIENT
CARE TEAMS IN AN
INTERPROFESSIONAL
CONTEXT
CORE COMPETENCIES for
INTERPROFESSIONAL
COLLABORATIVE PRACTICE
 Values/ethics for interprofessional practice
 Roles/responsibilities
 Interprofessional communication
 Teams and teamwork

(American Interprofessional Education Collaborative Expert
Panel, 2011)
CURTIN INTERPROFESSIONAL CAPABILITY
FRAMEWORK
(Brewer & Jones, 2013)

From Triple to Quadruple Aim: Care of the
Patient Requires Care of the Provider
The primary Triple Aim goal is to improve the health of

the population, with 2 secondary goals—improving patient experience and
reducing costs—contributing to the achievement of the primary goal.
Rising “I can’t tell you how defeated I

expectations of “The joy of practicing medicine “I hate being a doctor…I can’t feel…The feeling of being
physicians and is gone.” wait to get out.” punished for delivering good
care is nerve-racking.”
practices
“I am no longer a physician but

the data manager, data
entryclerk and steno girl… I
became a doctor to take care
ofpatients. I have become the
typist.”
CARE TEAM WELL-BEING AS A PREREQUISITE FOR THE TRIPLE

From Triple to Quadruple Aim: Care of the
Patient Requires Care of the Provider
The primary Triple Aim goal is to improve the health of

the population, with 2 secondary goals—improving patient experience and
reducing costs—contributing to the achievement of the primary goal.
Burnout affects not only Physician and staff

physicians, but also other dissatisfaction feed on each
Staff Burnout members of the health care
workforce. other.
“It’s really rough to be

around a burned-out doctor.
They’re cynical, sarcastic,
and wonder, ‘what’s the
use anymore?’”
CARE TEAM WELL-BEING AS A PREREQUISITE FOR THE TRIPLE

Who
lives?
Who
dies?:
PATIENT CARE Ethical
MANAGEMENT: PATIENT
SELECTION criteria in
patient
selection
PATIENT SELECTION
Who Lives? Who Dies?:
Whether implicitly or explicitly,
the perceived value that an Social value criteria are One of the fundamental bases
based on the idea that limited underlying the social value
individual has within society
healthcare resources should be doctrine is that society as a whole
plays a role in determining
allocated to those individuals has invested thousands of dollars
whether the person is selected to
who, if saved, will be the greatest and limited resources into an
receive limited healthcare
benefit to society. individual's treatment.
resources.
Therefore, these resources should

This allows the country,
be allocated to those individuals as a whole, to get a
who, in the future, will most return on its
contribute back to society.
investment.
John F. Kilner, Who Lives? Who Dies? Chapter 3, 1990

PATIENT SELECTION
Since social value criteria would

disproportionately exclude
minorities from allocation of limited Therefore, explicit use of the
healthcare services, a strong social value criteria in patient
argument could be made that such selection decisions should not
criteria should be subject to strict be considered.
scrutiny.
John F. Kilner, Who Lives? Who Dies? Chapter 3, 1990

PATIENT SELECTION
Not only are elderly patients being

denied limited resources, but in
Age should not be considered in many cases are deprived of basic
rationing health care services. care so that physicians may
concentrate their time, (also
limited), on younger patients.
Micheal Terry: When Did We Decide To Execute Our Old and Our Frail, The Express; World Reporter at 1, (Dec. 7, 1999).
PATIENT SELECTION
Rationing decisions, which result in

the withholding of potentially
Such legitimacy and accountability
beneficial treatment from patients in The guidelines on which patient
cannot exist when patient-selection
need, cannot be made based on selection decisions are based must be
criteria are developed in a closed-
guidelines developed behind closed available to the patients and public
forum setting inaccessible to the
doors. Any system, that rations whom these criteria affect.
public.
limited resources, must be
legitimate.
Ole Frithjof Norheim, Health Care Rationing--Are Additional Criteria Needed For Assessing Evidence Based Clinical Practice Guidelines? 319 British Medical Journal 1426, (Nov. 27,
1999).
PATIENT SELECTION
Rationing decisions, which result

in the withholding of potentially
beneficial treatment from patients Any system, that rations limited
in need, cannot be made based on resources, must be legitimate.
guidelines developed behind
closed doors.
Ole Frithjof Norheim, Health Care Rationing--Are Additional Criteria Needed For Assessing Evidence Based Clinical Practice Guidelines? 319 British Medical Journal 1426, (Nov. 27,
1999).
PATIENT SELECTION
Rationing criteria within this

system has resulted in
inequitable distribution of
resources based solely on
social and medical
considerations.
Robert H. Blank, Regulatory Rationing: A Solution to Health Care Resource Allocation, 140 U. Pennsylvania L. Rev. 1573 (1992).
PATIENT SELECTION
A system, which must explicitly Because of the implicit beliefs

ration the allocation of limited that the disabled, the elderly, and Therefore, whoever is charged
healthcare resources, the poor are less able to with making patient selection
encompasses thousands of positively contribute to society, decisions must be insulated from
difficult decisions involving who these groups are likely to bear such beliefs.
lives and who dies. the burden of societal prejudices.
George P. Smith II, Our Hearts Were Once Young and Gay: Health Care Rationing and the Elderly, 8 University of Florida Journal of Law and Public Policy, 1, (1996).
PATIENT SELECTION
A system, which must

Therefore, a lottery or any
explicitly ration the allocation
other "chance" method of
of limited healthcare resources,
allocating limited resources is
encompasses thousands of
inappropriate in our healthcare
difficult decisions involving
system.
who lives and who dies.
David Orentlichter, Destructing Disability: Rationing of Healthcare and Unfair Discrimination Against the Sick, 31 Harvard Civil Rights-Civil Liberties L. Rev. 49, (1996).
PATIENT SELECTION
Both explicit and implicit racial

discrimination exist in the current Physicians and health care providers
system of health care rationing have traditionally written off these
within the United States. systemic inequities, within the
Unconscious treatment decisions rationing of services, as a result of
often result in racially unequal cultural differences.
rationing practices.
Barbara A. Noah, Racial Disparities in the Delivery of Health Care, 35 San Diego L. Rev. 135 (1998).
PATIENT SELECTION
Both explicit and implicit racial

discrimination exist in the current Physicians and health care providers
system of health care rationing have traditionally written off these
within the United States. systemic inequities, within the
Unconscious treatment decisions rationing of services, as a result of
often result in racially unequal cultural differences.
rationing practices.
Allen v. Mansor, 681 F.Supp. 1232 (E.D. Mich. 1986)

PATIENT SELECTION
Who Lives? Who Dies?
Physicians take an oath to
put the care of the patient The physician, by the nature of
first and foremost in their her profession, is best situated
to make the difficult, life or
practice. The medical death decisions involved in the
rationing of limited resources.
profession is rooted in long-
standing ethical guidelines.
PATIENT CARE
MANAGEMENT:
PHYSICIAN'S PRACTICE
PATTERNS
HOW CAN WE PERSUADE CLINICIANS TO
ADOPT PROVEN PRACTICES?
PHYSICIAN'S PRACTICE PATTERNS
Patterns of practice related Do not confuse with

Variations in physician Practice Patterns
to diagnosis and treatment as PROFESSIONAL
practice patterns have Professional
especially influenced by cost PRACTICE where emphasis
important implications for
of the service requested and is on individual physicians Clinical Practice Variations
quality and cost.
provided. & their practices.
Professional Practice
Clinical Practice Patterns Physicians Practice Patterns Physician Prescribing
Patterns
Diffusion, which is a term for
The relationship between a the adoption of new medical
The determinants of diffusion
specified research result and technology, also applies to
include the following (1, pp.
changes in medical practice is altered ways of using
178-181):
very complex. technology, such as might result
from an effectiveness study.
Ease of learning a new practice The importance of the clinical

Prevailing medical theory: A
style: How much effort is problem: Is the problem one
change in medical practice is
involved in changing habits that that is likely to lead to death or
more likely to be adopted if it
have been ingrained and disability for one's patients? If
builds on existing theory and
polished through years of so, the physician is more likely
medical logic.
practice? to make the effort.
178-181):
The practice setting: Does the physician

Characteristics of the adopting physician: belong to a group practice in which there
Advocacy by a professional leader: There Have physicians' training prepared them is a lot of peer pressure to change? Are
is evidence that opinion leaders in the to grasp new concepts quickly and see the there financial pressures to change, either
medical community can influence their implications for their patients? Do they to do more procedures in fee-for-service
colleagues to adopt new practices. have the ability to change from one style practice or to do fewer in a prepaid
to another? practice? Are the new technologies
available in the practice setting?
178-181):
The results of formally evaluating The effectiveness of the channels of communication

The physician's control over
the technology: This component is of evaluation findings: If physicians are not aware of
decision making: Do physicians the results of a formal evaluation of a technology, its
the one with which the Effectiveness influence will be much diminished or delayed in
have direct control over the
Initiative is most concerned. The taking effect. Both the professional and the popular
decisions to acquire new technology media are important in disseminating information
evidence that formal evaluation
or to make it easier or more difficult about technology, and the influence of the popular
affects medical practice will be media on patients' expectations of their physicians is
to obtain access to the technology? a topic that is particularly neglected.
discussed later.
PHYSICIAN'S PRACTICE PATTERNS:
EVER-CHANGING LANDSCAPE
Second, we should look to the professional societies to
The physician's control over decision making: Do
identify effective clinical policies. Their
physicians have direct control over the decisions to
recommendations should be based on research results,
acquire new technology or to make it easier or more
with clear delineation of the logic leading from the
difficult to obtain access to the technology?
research findings to the recommendations.
Organizations that pay for health care will be doing Finding the truth about what works in the practice of
their part to motivate physicians, but we need more medicine will be an ongoing task, in which constantly
vigorous programs to teach physicians how to deal improving research methods are aimed at evolving
responsibly with fiscal pressures. technologies.
The COVID-19 crisis presented Consider this, a survey of

our society with a host of physicians conducted at the height
unexpected challenges and of the COVID-19 crisis found that
changes that could impact the way nearly half of its respondents
we interact with co-workers, (48%) were treating patients via
family members – and doctors. telemedicine.
60% of physicians who

Findings from the 21% of physicians have
38% of physicians are are not seeing COVID-19
been furloughed or
survey include: seeing COVID-19 patients patients are willing to do
experienced a pay cut
so
30% who are treating

18% plan to retire,
14% of respondents plan COVID-19 patients are
temporarily close their
to change practice settings feeling great stress but
practices, or opt-out of
as a result of COVID-19 will continue to see
patient care
patients
PATIENT CARE
MANAGEMENT: POINT-OF-
CARE SYSTEMS
POINT-OF-CARE SYSTEMS
These include
Laboratory and other diagnostic and
services provided to laboratory testing
patients at the bedside. using automated
information entry.
Testings, Bedside; Testing, Bedside; Technology, Bedside;
Technology Points, Care; Technology Point, Care;
Technologies, Bedside; Systems, Point-of-Care; System,
Point-of-Care; Point-of-Care System; Point of Care Systems;
Computings, Bedside; Computing, Bedside; Care
Technology Points; Care Technology Point; Bedside
Testings; Bedside Technologies; Bedside Computings;
Bedside Technology; Point of Care Technology; Bedside
Testing
POC systems replace many

functions of the paper chart and, in Clinicians use POC systems to
fact, are sometimes referred to as record directly details of patient
electronic medical records encounters, to review information,
(although that term is used so and to order tests and other
loosely that we recommend that it is services.
not used).
Vendors sell POC systems

specialized for diverse settings, POC systems even exist for
including the emergency department, prehospital care settings. Emergency
physician offices, hospitals, intensive medical units may use “ruggedized”
care units, long-term care facilities, handheld computers in the field.
and home health care.
quicker access to clinical information
the ability to communicate orders more quickly,
Advantages of POC systems to a hospital include
elimination of the difficulties involved in reading the products of

poor penmanship,
the ability to harness integrated decision-support tools such as

electronic formularies, drug interaction warning databases, and
electronic implementations of practice guidelines.
POC systems are the future of

biosurveillance. A POC system facilitates the
electronic capture of key diagnostic data (and
usually in a computer-interpretable form
rather than English).
Advantages of POC systems to a hospital
include
POC systems typically include decision-

support capabilities that alert clinicians to
potential drug–drug interactions and even
suggest diagnoses.
Lazarus et al. (2002) has claimed that a POC system (a
commercial product Epicare; Epic Systems Corporation,
Madison, Wisconsin; http://www.epicsys.com) can be effective
for purposes of public health reporting and bioterrorism early
warning even if it serves only 5% to 10% of the population in a
region being monitored. More research with POC-based
surveillance is required to elucidate the relationship between the
completeness of sampling of a population and the size of
outbreaks of different diseases that can be detected.

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PATIENT CARE

The CCM model is a team-driven model

The key characteristics of the patient-centered medical home

A key metric in the independence at home

Blockchain technology’s capacity to generate complete

A dedication to analyzing patient data

Studies show that 88% of consumers are willing to share

Precision medicine can help reduce acute hospital

Care management is a set of activities

Payment reform may

Offering care management to

Care management is a promising

Informal caregivers: Patients with

Most care management findings are from

Commercial disease management

The most effective care management Home-based care management programs

Care management programs that

Payment reform may Absent a broad scale

A system that enrolls or assigns patients

Providers must be able to identify

Careful management of select Patient characteristics such as ethnicity,

Outreach. Outreach to patients is a

Once patients’ needs for CM services have been

There is still much to learn about the By practices working diligently to

CAPACITY Range of services

Source: Starfield. Primary Care: Balancing Health Needs, Services,

Health Illness Community

People’s involvement in the planning

The commitment to global improvements

For Restorative When care is

CQI, which focuses on processes and

Karen Zander (who developed the

Health care team

Consider what can

That is problematic in cost and/or quality data

With written standards, guidelines, and protocols available in authoritative sources

Literature search— Steering group— Paperwork design—

Pilot program— Preliminary findings— Refine the program— Full implementation—

Standardized care from Promotion of the

As a result, the new medication regimen

When a patient’s transition from the

to communicate "a complete list of the The Joint Commission

An up-to-date and accurate A formal structured process

The process of medication

Staff responsible for

‘prn’ (i.e., “as needed”) medication

community pharmacists, physicians and/or home care providers

The medication inspection of medication containers

discrepancies in which the

‘prn’ (i.e., “as needed”) medication

Assessing a patient’s understanding of their

“WHO High 5’s Assuring Medication

Yarnall KSH, Pollak KI, Østbye T, et al. Primary care:

Medical assistants (MAs) can Pharmacists can conduct

 Values/ethics for interprofessional practice

 Teams and teamwork

(Brewer & Jones, 2013)

The primary Triple Aim goal is to improve the health of

Rising “I can’t tell you how defeated I

“I am no longer a physician but

CARE TEAM WELL-BEING AS A PREREQUISITE FOR THE TRIPLE

The primary Triple Aim goal is to improve the health of

Burnout affects not only Physician and staff