Care Management (Service Option 3)

Care Management is the nursing practice of coordinating healthcare and other services received by a client at home or in an institutional setting. Besides coordinating client care, the nurse care manager:

   • Advocates for the client.
   • Works to prevent illness and accidents.
   • Helps the client to attain and maintain optimal health, comfort, safety, and independence.

Nebraska Nursing Consultants provides care management service that is independent and professional. We are not affiliated with any physician’s office, assisted living home, nursing home or hospital. Each of our Registered Nurses is a seasoned professional with years of nursing experience. Our service is considered “primary care nursing,” which means that each client has her/his own Registered Nurse. Our clients are seen and attended to by the nurse they know.

Our services, as described below, may or may not fit your needs. The advantage of private practice is that we can be innovative and flexible. We put together an individualized care plan for each of our clients. Our services are not limited to what is listed below. We can design more service, different service, or less service. Call us. Together, we’ll address health, safety, comfort and, along the way, maybe find joy.

Care Management Sub-Services:
1. Standard Care Management Services
2. Other Care Management Services
3. Who Are Our Clients?
4. Frequency of Visits
5. Responding in an Emergency
6. Coordinating Care
7. Staying in Touch with Family

The NNC Nurse Care Manager:

• Visits the client wherever she/he may be.
  
• Evaluates how the client manages medications and treatments.
  
• Monitors the effects and side-effects of medications and treatments.
  
• Monitors changes in the client's physical condition and behaviors.
  
• Monitors changes in the client's ability to perform the activities of daily living—eating, dressing, undressing, toileting, hygiene, mobility.
  
• Monitors changes in the client's ability to maintain an independent household—taking prescribed medications correctly, handling personal finances, transporting him or herself or arranging transportation, managing stairs, shopping, preparing meals, doing routine housework and laundry.
  
• Recommends appropriate care options and household helpers.
  
• Responds day or night to client, caregiver or family calls.
  
• Responds to distant alert systems such as Lifeline.
  
• Reviews client’s chart, monitors care and advocates in hospital, assisted living, group home, nursing home or memory support unit.
  
• Communicates with family and health care providers.
  
• Unique to Nebraska Nursing Consultants, the NNC nurse accompanies her client to the emergency room. She stays as long as her client stays. She monitors care and advocates to be sure her client gets good care and that established directives are honored. If her client is admitted to the hospital, the NNC nurse visits daily to monitor care and keep family informed.

NNC Nurse Care Managers May Also:

• Accompany the client to appointments with physicians and other health care providers.
  
• Set up and monitor a safe home medication system.
  
• Evaluate and advise client and family about appropriate housing.
  
• Help with moving decisions and facilitate moving arrangements.
  
• Arrange for other health services such as a comprehensive medical assessment, dental appointments, psychological counseling, Physical, Occupational, Speech and Hearing Therapy screenings, automobile driving evaluation, and even Music Therapy.
  
• Arrange for and supervise companion, homemaking, and nurse aide services.
  

3. Who Are Our Care Management Clients?
Our Care Management clients live in private homes, retirement centers, assisted living apartments, group homes, nursing homes, and memory support units. Although most of our clients live within a fifty-mile radius of Lincoln or the Grand Island-Hastings-Kearney area, special arrangements may be possible to serve those who live elsewhere. Most of our Care Management clients’ families live out of town, travel frequently or spend winter or summer months at vacation homes. Some have no family.

Although most of our clients in Care Management are elderly or disabled, we also provide services for people of all ages and abilities, including children. Generally our clients are individuals or couples, one or both of whom may be coping with chronic illness, balance, or memory problems. Peace of mind can come from having a nurse who visits regularly, monitors changes in health, safety, and comfort, and responds in a crisis. Sometimes it’s hard to say who is more relieved, the client or the client’s family!

4. Frequency Of Visits
It is a requirement of our Care Management service that clients be visited at least every two weeks. Within that framework, the frequency of visits is flexible—related to client condition, client and/or family request, and the nurse’s professional judgment. The nurse’s professional judgment is especially important when client safety is at issue.

Our nurses are careful with clients’ time. Our aim is to be efficient and effective. For example, when a physician prescribes new medication, the NNC RN will visit to check her client’s response but her visit will last only as long as it takes to make a good assessment.

Often families first call us when a crisis looms. This necessitates more frequent visits because there is work to be done to get to know the client, ensure safety, and establish a good plan of care. Then, as things settle down, visit frequency can sometimes be reduced. However, in monitoring some chronic illnesses, weekly or bi-weekly visits may continue to be necessary to ensure safety. Decisions about the frequency of visits are made by the NNC nurse in consultation with the client and family.

When or if visits every two weeks are no longer desired, client, family and nurse may explore NNC’s Continuing Consultation service option.

5. Responding In An Emergency
Nebraska Nursing Consultants nurses are on-call for their Care Management clients every hour, day and night. Back-up is provided by other NNC RN's in the Registry.

When our nurse receives a call from a client in distress, the nurse makes a telephone assessment, then either visits or calls 911.

If she deems it safe, the nurse makes an immediate visit, assesses and proposes appropriate action which may include contacting the physician, transporting the client to the emergency room or calling 911.

Or, if the situation warrants, the nurse may call 911 and then meet the client at the emergency room. In the emergency room, the NNC nurse is the familiar face--there to reassure her client, to communicate with family and health care providers, to monitor care and to advocate to be sure that the client gets good care and that established directives are honored.

Always, the nurse stays with her client until the client’s situation is stable. Then, if the client is discharged from the ER or admitted to the hospital, the NNC nurse may, with family approval, arrange for helpers to stay with the client. If a client is admitted to the hospital, his/her NNC nurse visits daily to monitor care.

6. Coordinating Care
When one has relatively good health, coordinating care is not an issue. But a person with chronic illness or memory problems can be overwhelmed by trying to manage his/her own healthcare services. When several physicians, therapists, and household helpers are involved, health care may quickly become fragmented. Too often, optimal care is sacrificed simply because the right hand doesn’t know what the left hand is doing. When Nebraska Nursing Consultants Registered Nurses advocate and monitor care, they communicate and coordinate the work of all care providers and helpers. It’s well worth the effort.

NNC’s Registered Nurses advocate and monitor care; they communicate and coordinate the work of care providers and helpers. This is Care Management. Our clients and their families tell us we do this rather well.

7. Staying In Touch With Family
With the permission of her client, the nurse telephones or emails to update family members. With the push of the send button, she can email the daughter in Seattle, the son in Texas, and the granddaughter in Boston a quick update about what happened at the doctor appointment today, or reassure that the plumber is coming this afternoon, or that today their relative walked 12 feet with his walker! Of course, when matters are urgent, the nurse is on the phone to family to inform and reassure that she’s there to monitor and advocate. She first phones the person holding durable power of attorney for health care.

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