Managed Care: Practice Strategies for Nursing
Publication Year: 1999
Of all the recent changes in health care, none more dramatically affected both patients and care providers than managed care. Not only has it altered the way we pay for health care, but also it has compelled a change in the way we approach health care, focusing increasingly on preventive care to reduce costs. In this book, the author and her colleagues examine the impact of managed care on nursing as a profession and nurses as individual caregivers. Managed Care: Practice Strategies for Nursing will serve as an excellent course text on nursing and managed care, as well as a useful introduction and shelf reference for professional nurses at all levels of practice.
- Front Matter
- Back Matter
- Subject Index
Part I: Managed Care Environment
- Preface: Introduction to Managed Care Strategies
- Chapter 1: Health Care Reform: An Opportunity for Nursing
- The Window of Opportunity
- Threats to Nursing
- Managed Health Care Organizations
- Factors Affecting Health Care Delivery
- Health Care in the United States
- Changes Needed in the Health Care System
- Chapter 2: Managed Care Organizational Structures
- Description of Managed Care
- Development of Managed Care Organizations
- Capitation Principles
- Health Maintenance Organizational Structures
- Alternate Types of Managed Care Arrangements
- Elements of Financial Risk
- For-Profit versus Not-for-Profit Managed Health Care Plans
- Federally Financed HMOs
- Other Federally Financed Health Programs
- Chapter 3: Managed Care Organizational Strategies Used to Achieve Organizational Goals
- Integration of Services
- Coordination of Care
- Health Promotion Strategies
- Quality Management
- Chapter 4: Nursing Involvement in Quality of Care Issues
- Traditional Quality Measurement Techniques
- Specific Quality Indicators
- Ethical Principles
- Model for Assessing the Quality of Nursing Care
- Measurement of Cost-Effectiveness
- Chapter 5: Nursing Case Management: A Managed Care Organizational Strategy
- Origins of Nursing Case Management
- Definitions of Nursing Case Management
- Models of Nurse Case Management
- Goals of Nurse Case Management
- Skills Required for Nurse Case Management
- Who is the Case Manager?
- Educational Preparation for Nurse Case Management
- Which Clients Require Case Management?
- Chapter 6: Use of Nurse Extenders
- Reasons for Use of Nurse Extenders
- Who is the Nurse Extender?
- Educational Programs for Unlicensed Nurse Personnel
- What is the Role of the RN When Working with the UAP?
- Education Needed for Registered Nurses for Effective Teamwork
- Clinical Example
- Chapter 7: Advanced Practice Nurses: Acute-Care Settings
- Advanced Practice Nurse Roles in Acute-Care Settings
- Acute-Care Nurse Practitioner
- Overlap between CNS and ACNP Roles
- Chapter 8: Nurse Case Management: Acute-Care Hospital Practice
- Admission Activities
- Concurrent Review
- Functions of the Nurse Case Manager during the Hospital Stay
- Discharge Process
- Chapter 9: Automated Clinical Pathways in the Patient Record: Legal Implications
- The Clinical Pathway
- The Clinical Pathway as a Documentation Tool
- Interdisciplinary Clinical Pathway Development
- Outcome-Focused Care
- Example of an Automated Clinical Pathway
- Legal Implications
- Legal Considerations for Use of Computer Documentation System
- Chapter 10: Clinical Pathway Outcome Research
- Examples of Outcome Studies
- Research Study
- Chapter 11: Nurse Case Management in Community Settings
- Long-Term Care
- Home-Based Programs
- Parish Nursing
- Physician Office Case Management
- Chapter 12: Population-Based Nurse Case Management
- Population-Based Case Management
- Methods Used in Population-Based Case Management
- Case Management Based on Living Circumstances
- Case Management of Special-Needs Infants
- Case Management of High-Risk Pregnancy
- Case Management of the Elderly
- Chapter 13: Advanced Practice Nurses as Case Managers
- Advanced Practice Role: Nurse Case Manager
- Disease-Specific Nurse Case Management
- Chapter 14: Advanced Practice Roles in Community Settings: Community Health Clinics
- Health Management: The Teen Population
- Health Management: Uninsured Populations
- Chapter 15: Advanced Nurse Collaborative Practice in a Primary Care Setting
- Need for APNs in Primary Health Care Settings
- Evolving Roles for Advanced Practice Nurses
- Model of Collaborative Practice between APNs
- Example from Clinical Practice
- Advanced Practice Roles for Nurses in the Center
- Uniqueness of APN Collaboration
- Evaluation Methodologies
- Client Situations
Copyright © 1999 by Sage Publications, Inc.
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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Library of Congress Cataloging-in-Publication Data
Conger, Margaret M.
Managed care: Practice strategies for nursing / by Margaret M. Conger.
Includes bibliographical references and index.
ISBN 0-7619-0964-8 (cloth: acid-free paper)
ISBN 0-7619-0965-6 (pbk.: acid-free paper)
1. Nursing—Effect of managed care on. 2. Nursing—Practice. I. Title.
98 99 00 01 02 03 04 10 9 8 7 6 5 4 3 2 1
Acquiring Editor: Dan Ruth
Editorial Assistant: Anna Howland
Production Editor: Wendy Westgate
Production Assistant: Nevair Kabakian
Typesetter/Designer: Marion S. Warren
Indexer: Molly Hall
Preface: “Old Wine in New Wine Skins”[Page xi]
We have long been told that new wine in old wineskins will cause the skins to burst (Matthew 9:17). Perhaps today we need to turn this around and think about the effect of old wine in new wineskins. Many nurses are still trying to shape their practice to methods that have worked in the past—but health care delivery systems have changed. What is needed now is to invent new ways to deliver nursing care in the new environment. The purpose of this book is to provide nurses with an opportunity to explore the new environment (the wine skin) and how to produce new wine—nursing practices that meet the new health care environment's needs. The changes that managed health care is bringing will be explored; ways that nurses can grow professionally in this new environment will then be discussed.
Nursing students need to understand the changing world of health care that they will encounter on entry into practice. Staff nurses also need to have a resource to assist them in understanding the changes they encounter on a daily basis. It is hoped that this book will assist both neophyte nurses and those who have long been established in practice to take steps to manage the destiny of nursing.
Many of the elements important to nursing in the past are still relevant to practice today, but these elements need to be recast to meet the needs of the new environment. Old recipes for winemaking need not be discarded, just adapted to the present environment. With the current market pressures moving [Page xii]health care toward an emphasis of wellness promotion, avoidance of illness, and efficient management of expensive resources, nurses are in an excellent position to move into this new paradigm. Long-held nursing ideals such as focusing on health and wellness, patient advocacy, and caring for the individual within the context of his or her environment are vital to successful practice in the changing environment. It is a paradox that our future survival will, in part, be determined by our ability to return to some of our fundamental roots. Florence Nightingale left an indelible stamp on the nursing profession when over a century ago she advocated for nurses to
care for the sick at home as well as in the hospital, and to serve all kinds and classes of people, rich and poor, the mentally disabled, and families and communities as well as individuals. The teaching of health maintenance and the prevention of sickness is to be an important part of their work. (Hay, 1993, p. 149)
These principles are still relevant today. Managed care organizations are beginning to place economic value on health promotion rather than on a singular focus on the technical care of acute health crises. This new concern for health promotion is an opportunity that nursing must not miss. Now is the time to reinvent nursing to meet the challenges of the managed care environment.
This book is about the managed care health system and the changes that it has brought to nursing. The managed care movement will be examined in the first section of this book. The foundational principles upon which it operates will be explored and the terminology used to describe the multitude of forms that it can take will be introduced. A brief review of the history of medical care in the past 50 years will also be discussed to provide a basis for understanding why change was necessary. The concerns that nurses are expressing about their future will also be examined.
After a foundation has been laid for understanding the important elements of managed care, the remainder of the book will focus on strategies that are being used by nurses to conduct their practice in the emerging health care system. Many of the strategies discussed are useful both in the more familiar acute-care hospital-based practice and in the multitude of newly emerging community settings. Nurses, armed with both learning from past experience and knowledge about the pressures, needs, and trends of the current health [Page xiii]care marketplace, will be in a strong position to mold and shape their own future.Acknowledgments
This book is a reflection of the thinking of many people. First and foremost, much of the content has grown out of conversations between JoAnne Woodall and myself as we spent a year driving once a week from Flagstaff to Tucson, Arizona to study case management at the University of Arizona. I am also grateful for the wisdom, insight, and leadership of Rose Gerber, RN, PhD, of the University of Arizona for allowing JoAnne and me to study nursing case management along with the University of Arizona graduate students. Finally, much of the content of this book has been reviewed, discussed, and even challenged by my graduate students at Northern Arizona University. All of these people have had a significant impact on the content included in this book. Without the input and encouragement of each of these people, this project would not have been possible.Northern Arizona UniversityReference[Page xiv]1993, October). Nursing's renaissance. Health Progress, 74(3), 26–32.(
About the Editor[Page 288]
Margaret M. Conger, RN, EdD, is Associate Professor of Nursing at Northern Arizona University. Her teaching responsibilities there focus on the development of a rural health clinical track in the graduate program that includes a strong focus on case management principles as applied in the managed care environment. She has completed postgraduate work in case management at the University of Arizona and has a number of publications in this area.
About the Contributors[Page 289]
Lisa Brugh, RN, MS OCN, is the Clinical Pathways Coordinator at Flagstaff Medical Center in Flagstaff, Arizona, where she has facilitated the development of over 20 automated clinical pathways. She has done graduate work at Northern Arizona University, where her emphasis is on case management strategies that enhance collaborative care practices.
Carol E. Craig, RN, PhD FNPc, is Associate Professor in Nursing at the Oregon Health Sciences Center at Oregon Institute of Technology. She was formerly an Associate Professor of Nursing at Northern Arizona University. She is a certified Family Nurse Practitioner and has maintained her practice at the North Country Community Health Center. She was instrumental in establishing this center as a free clinic to serve the needs of the medically underserved in the community, and she obtained federal funding for the project.
Teri Fernandez, RN, MS, is the owner of Northland Medical Case Management in Prescott, Arizona, where she actively works as a case manager with worker's compensation clients. She has had extensive experience in community-based case management services. She has also participated in developing items for case management certification exams.
Kathy Ingleses, RN, MS, FNP, is Assistant Clinical Professor in Nursing at Northern Arizona University. She also practices as a Family Nurse Practitioner [Page 290]at The Teen Clinic, which is a part of the School-based, School-linked Services program through the Coconino Department of Health Services in Flagstaff, Arizona.
Pamela Keberlein, RN, MSN, is the nursing coordinator for the bedside computer system at Flagstaff Medical Center, Flagstaff, Arizona. In this role, she developed and implemented one of the first bedside computer systems in the United States that incorporated the clinical pathway as part of the documentation system. She has had many years of clinical nursing experience in critical care and surgery. Her current research interests are the effects of managed care and clinical pathways on patient care.
Deanne Lewis, RN, MS, is actively working in case management with worker's compensation clients and is also teaching case management to nursing students. She has had extensive experience in community health nursing.
JoAnne Woodall, RN, MSN, is currently the team leader for case management at Tucson Medical Center in Tucson, Arizona. She developed the first case management program at Flagstaff Medical Center and has done postgraduate work in case management at the University of Arizona.