who is typically the case manager?
nurse or a social worker
List duties a case manager typically has
- screening to ID appropriate pts for case management services
- planning and coordinating delivery of care by healthcare team
- making D/C arrangements and following up w/pt
- evaluating outcomes of care for each pt
- checking benefits and coordinating w/other benefits
- recommending insurance policy coverage exceptions where appropriate
- coordinating referrals to specalists
- coodinating care w/community services
- verifying med reasons for employee absences
- edu workers w/chronic conditions
what should PTs communicate to case managers?
- status and needs of the pt related to our professional eval
- need to know info to the case manager related to PT needs of the pt
when do you begin D/C planning?
Day 1
where do you note anticipated D/C plans in the initial eval?
documentated in the POC
summarize the purpose of the episode of care summary
to give a big summary of the pt’s outcomes during PT
(essentially a D/C summary)
outline the criteria for the conclusion of the episode of care
- achievement of goals/optimal level of function
- lack of progress/no longer requires skilled care
list the components of the episode of care summary
- current physical/functional status
- criteria/justification for termination of PT services in that setting
- degree of goals/outcomes observed
- reasons for goals/outcomes not being achieved
- plans related to the pt or client’s continuing care
describe what is include in the following component:
current physical/functional status
- update the pt’s current functional status to reflect where they are at at the completion of the episode of care
describe what is included in the following component:
criteria/justification for termination of PT services
- provides support for the termination of PT services
- here you relay the results of your reexam and outline your clinical impression of the course of care
- include a justification as to why skilled care is no longer needed
- if impairments remain, include justification as to the plan of how the remaining impairments will be addressed
describe what is included in the following component:
degree of goals/outcomes met
- bascially, providing an update on goal achievement status
- including all goals written througout the course of care (even if goal was achieved by the first reexam)
- can indicate achievement status with ratio (50% met) or simply with statement of goal met/not met
what are some rationale for why goals or projected outcomes were not acheived
- could be due to:
- an unforeseen change in status
- a plateau of pt progress
- continuing PT is no longer feasible
- skilled PT is no longer needed
what should be included in plans related to pt continuing care?
- HEP
- referrals for additional services
- recommendations for follow-up PT care
- family/caregiver training
- equipment provided
