Objective                                                                                                                                               

    Case Managers will, 

    Understand the roles and responsibilities as a Case Manager within the Navy Medical Treatment Facilities (MTFs), understand the populations served and obtain an introduction of their role within the MTFs chain of command. Be introduced to the Case Management Competences, Case Acuities and Change Theories.  Have an understanding of the mission of BUMED as an advisory entity and resource to all Navy Case Management.    

    BUMED                                                                                                                                                                                                    

    The Navy Bureau of Medicine and Surgery is the headquarters command for Navy Medicine.  Under the leadership of the Navy Surgeon General, Navy Medicine provides leadership to Navy Medicine in establishing strategic goals: 

    The mission of BUMED Case Management Department is, 

    • Navy Medicine’s point of contact for the Case Management Program, working closely with Navy Safe Harbor and Marine Corps Wounded Warrior Regiment, caring for both Active and Reserve Wounded Ill and Injured and all beneficiaries.
    • Management for the Case Management program.  Provide direction, oversight, resource acquisition and coordination for the Case Management program.  Provides guidance on documentation standards, data management and collection and education and training for case management personnel located within the Navy enterprise.    
    • Directs and coordinates system wide improvements, quality control, and standardization of the case management program. 
    • Provides Navy Medicine SME’s in Case Management in support of Navy Medicine.  Advises Chief, BUMED/SG on issues related to Case Management and care coordination. Provides SME’s for initiatives on a wide range of programs and initiatives governed or regulated by higher authority or Federal agencies.  
    • Provides consultative services to Regional Command staff.  

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    Roles and Responsibilities of the Navy Case Manager Within the MTF Chain of Command                 

    Each Navy Military Treatment facility including regional health clinics is able to make decisions about the types of cases a Case Manager should handle.  However, per BUMED Instruction for Navy Case Management, BUMED INST 6300.17, all Navy Case Managers must assess all ADSMs who are injured as a result of OIF/OEF for case management needs.  Per Nav Med Policy 06-002 Standard Organization Guidance, Case Management would fall under the Business Operations if the recommended MTF organization structure is followed.

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     Case Management Competencies                                                                                                         

    Newly hired Navy Case Managers will be developing and mastering many skills over personal time frames that will depend largely on individual and command variables.  The following information will help the new Case Manager and their Lead Case Managers review and evaluate skill development in case management and case management documentation.  

    Case Managers record is reviewed or Case Manager is interviewed or observed to determine if the following standards were met: (more comprehensive listing of skills is found in the Competency Form)

    • Patient has signed a consent form for case management services.
    • Assessment was completed as related to appropriateness of the level of care, diagnostics, and procedures performed,
    • Assess physical, psychological and social needs of the patient,
    • Assess patient and family support education needs,
    • Assess financial needs, barriers to learning
    • Plan of Care is based on patient/family interviews, medical record review and assessment of other factual information
    • For each problem an intervention is noted
    • Short and long term goals are determined with designated time frames
    • Patient/family/caregiver educational materials are noted
    • Life style/role changes are addressed,
    • Specific services to be provided are identified
    • Care plan is developed with input from the multidisciplinary team, patient and family
    • Life planning contingencies such as Power of Attorney and Advanced Directives are addressed
    • Formal Care Plan is completed with 30 days of acceptance and updated monthly
    • Documentation reflects case manager is facilitating and coordinating patient care activity, assure recommendations in the care plan are implemented and continuity of care is maintained:
      • Communication with health care team members, e.g. Social Worker, primary care provider, specialists, rehabilitation therapists, etc,
      • Documents outcomes and variances of care as related to the Care Plan
      • Plan of care is based on variances of care,
      • Initiates/coordinates/collaborates with the healthcare team regarding referrals, e.g. equipment, LTC, home care, VA hospital, outpatient rehab
    • Initiates and follows through on discharge planning based on goals established by the care team
    • Documentation reflect intermittent checks to determine the effectiveness of the care plan and if the plan is meeting expected goals/time frames
      • Maintains regular communication with patient/family care giver regarding progress of needed changes to impact goals and outcomes
      • Communicates with healthcare team to review effectiveness of the plan of care and identifies early problems that would impact healthcare outcomes
      • Identifies barriers to care and seeks resolutions and communicates this to the healthcare team, patient/family/guardian
    • Based on monitoring controls, an evaluation statement is in place to describe outcomes and effectiveness of the plan
      • Reviews effectiveness of interventions and implementation
      • Reviews the care plan as required in collaboration with other health team members
      • Evaluates patient readiness for discharge plans
      • Documents goals met within established time frame and if not, rationale for not meeting goals
    • Documentation states why the case management services were ended/closed
      • Documentation designates ability to function independently or no contact after 4 attempts or refusal of services and provider notified that case management services were closed, patient relocated to another region and services received

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     Case Management Acuity Tool Developed by Health Affairs                                                                 

    The number of Case Managers required depends upon the composition (case mix/acuity) of the membership. Concurrently, a Case Manager’s caseload is dependent on many factors such as,

    • Charac­teristics of the patients served,
    • Complexity of the care plan,
    • Geographical area covered,
    • Amount of administrative support,
    • Availability of community-based services experience and competency of the case manager,
    • Control over funds used in the delivery of care

Documentation of the acuity of a case is imperative to determine an appropriate case load.   

    To manage case load, the current Navy Case Management acuity system is done via the documentation tool, AHLTA following guidelines set forth by Health Affairs.  All cases are entered using a coding system categorized from Level 1 (less complex and time consuming) to Level 5 (most complex and time consuming)

    Level 1
    Non-complex chronic cases that require the CM to follow up less than once a week (e.g. rehabilitation, extended convalescent leave periods, awaiting a medical board or further surgical intervention or medical treatment. G9002 

    Level 2
    Requires the CM to coordinate and follow up with up to 2 or more interventions (e.g. pharmacotherapy, DME/home health, healthcare team communications, social resources, transfers, and patient/family communications) 3-4 times per month (e.g. convalescent leave periods or requirement for occasional assistance with authorizations or appointments.  G9005 

    Level 3
    Requires CM to coordinate and follow-up with 4 or more interventions (e.g. pharmacotherapy, DME/home health, healthcare team communications, social resources, transfers, and patient/family communications) 1-2 times a week, less than 30 minutes each session. G9009 

    Level 4
    Requires CM to coordinate and follow-up with 6 or more interventions (e.g. pharmacotherapy, DME/home health, healthcare team communications, social resources, transfers, and patient/family communications) 3 times a week, less than 30 minutes each session (e.g. episodic crises cases that consume a day’s work -- Urgent case or other non-casualty high visibility case. G9010 

    Level 5
    Requires complex interventions from CM and a follow-up at a minimum of 3 times a week, greater than 30 minutes each session (.e.g. discharge from inpatient status with orders for interventions, completion of MEB/PEB process, and transfer to VHA facility or transition to independent living, assistance with authorization or appointments, counseling or reassuring/supporting caregivers of casualties, providing information).  These are acute/complex cases that require significant coordination and follow-up and may involve daily contact. G9011 

    It is also extremely important for acuity to be captured and effectively measured; the case MUST be entered into AHLTA with a V49.89 code as the primary diagnosis.  The use of modifiers after the standard V49.89 is also required.  The modifiers are,

    • _2 denotes “starting” a new case,
    • _3 is for coding continuation of a case and,
    • _4 ending or closing of a case.

    In addition to the primary diagnosis, ADSMs (active duty service members) who are considered wounded warriors must also have a secondary diagnosis of V70.5_G entered into AHLTA to be correctly captured 

    Lastly T codes are also allowed when case managers want to track the time they have spent with members and families.  This information is contained in the training material for AHLT Change management is typically defined as a structured approach to transitioning individuals from a current state to a desired future state.  

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    Change Theories for Case Managers                                                                                                    

    The six phases of a popular model for personal change

    1. Anticipation. The waiting stage. They really don't know what to expect so they wait, anticipating what the future holds.
    2. Confrontation. People begin to confront reality. They realize that change is really going to happen or is happening.
    3. Realization. Post change - Realizing that nothing is ever going to be as it once was.
    4. Depression. Often a necessary step in the change process. This is the stage where a person mourns the past. Not only have they realized the change intellectually, but now they are beginning to comprehend it emotionally as well.
    5. Acceptance. Acceptance of the change emotionally. Although they may still have reservations, they are not fighting the change at this stage. They may even see some of the benefits even if they are not completely convinced.
    6. Enlightenment. In Phase 6, people completely accept the new change. In fact, many wonder how they ever managed the "old" way. Overall, they feel good about the change and accept it as the status quo from here forward.

    It is important to note that patients proceed at different rates of speed. One patient may require two months to reach Phase 6 while another may require twelve. To make things even more complex, the cycle of change is not linear. In other words, a patient does not necessarily complete Phase 1 through 6 in order. It is much more common for patients to jump around. One person may go from Phase 4 to Phase 5 and then back to Phase 2 again. That is why there is no easy way to determine how long a change will take to implement. However, by using skills of a case manager you increase your chances of managing the change as effectively as possible.

    A natural reaction to change, even in the best circumstances, is to resist. Awareness of the need to change is a critical ingredient of any change and must come first.

    People and patients resist change when:

    • They believe change is unnecessary or will make the situation worse.
    • They fear that the change will mean personal loss - of security, money, status, friends or freedom.
    • They had no input into the decision.
    • The change was a surprise.
    • They are not confident that the change will succeed.
    • They feel manipulated because the changes were kept secret during the planning stage. 
    • They subscribe to the belief, "If it's not broken, don't fix it."
    • They believe that the system (personal, family, military health system, etc) lacks the necessary resources to implement the change.

    People support change when:

    • They expect that it will result in some personal gain.
    • They expect a new challenge as a result.
    • They believe that the change makes sense and is the right thing to do.
    • They were given an opportunity to provide input into the change.
    • They respect the person who is championing the change.
    • They believe it is the right time for the change.

    Case Managers should anticipate resistance to any change effort, prepare for it, and make special efforts to assess and deal with individual reactions to change. Case Managers must develop the proper attitude toward resistance to change and realize that it is neither good nor bad. In fact, resistance can serve as a signal that there are ways in which the change effort should be modified and improved. The following steps should help case managers faced with resistance to their change attempts:

    • Actively seek out patient’s thoughts and reactions to the proposed changes. 
    • Listen carefully. Do not launch into lengthy diatribes justifying the change - in the early stages, people are not interested in that. They want to be heard and have their concerns attended to. Recognize that it takes time to work through reactions to change.
    • Engage people in dialogue about the change. Case Managers should do this only after fully understanding the specific concerns of others. 
    • Involve Others

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