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Care Management PROCESS Guidelines
The following discussion guides you through the care management process and the use of the tool.
Depending on your practicum area and your population, the overall care management process could be
modified; however, the basic principles remain the same. The purpose of the care management process is
to enhance health states and quality of life for individuals, families, and populations. The process should
be client-centered and involve intra- and interdisciplinary collaboration. The clinical application of the
care management process should promote evidence-based care, enhance patient/population outcomes, and
provide a seamless transition between careproviders.
Beginning with Expected Outcomes, the care management process provides a deliberate, focused
approach to patient care. However, before planning and executing patient care, the provider must have a
clear idea of the expectations for the individual’s (patient’s or community’s) health alteration or disease
as it relates to the specific population’s profile within that particular health alteration or disease process.
I. Population Profile
A population profile is a brief and concise paragraph that describes the relationship of a health alteration
or disease to the specific population affected. The profile should provide a succinct description of the
context of disease as experienced by a population. This description should serve as the foundation for the
development of interventions at the health promotion and health protection levels of care delivery by the
care manager. The profile should enable you to view your individual client from a broader perspective
and help you to focus on all population-based aspects of the care management plan. Content for the
population profile can be obtained from textbooks, professional publications, local, state, and national
government publications, class lectures, etc. The following areas (as data availability allows) should be
addressed in this paragraph:
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General demographics and demographic trends of the population with a particular health alteration(s)
or disease(s);
Incidence rate;
Prevalence rate;
Risk factors commonly associated with the health alteration or disease;
Mortality data;
Morbidity (co-morbidity, complications or adverse events, nosocomial infections, reoccurrence of
previous conditions or disorders) data;
Social processes associated with this population (e.g., violence rates, legal encounters, etc);
Accessibility to care and usual setting for delivery of care.
Developmental milestones associated with this population (pediatric populations)
II. Desired Population Outcomes
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Expected outcomes are defined as end-points or anticipated and desired responses to treatment at
specified points along the disease episode or continuum of care (promotion, protection, restoration,
and maintenance).
Expected outcomes are based on the literature, research, best standards of practice, clinical pathways
or other sources considered to provide ample evidence that for specific diseases and populations
certain outcomes can be expected for that disease and population.
Outcomes may differ at different points along the continuum (e.g. health restoration outcomes may
represent specific and immediate physiological responses whereas outcomes at the maintenance level
may address more long-term functional and quality of life issues).
Keep in mind that there are three (3) broad categories of outcomes:
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A. Clinical outcomes such as mortality, morbidity, readmission, health status, infection, LOS (length
of stay)
B. Quality-related outcomes which are multidimensional and related to function, quality of life, and
satisfaction with one’s health
C. Cost-related outcomes which are direct medical costs of treatment and indirect social costs(delays
at work, decreased productivity, replacement workers, caregiver costs).
The SON operationalizes these outcome categories by identifying five (5) health states. Each
health state has been defined in order to help identify the appropriate outcome/s for care (see
section titled “Health State Outcomes Framework”).
Health States Outcomes Framework:
CATEGORY
Clinical Outcomes
HEALTH STATE
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Physiological Health States
Mental Health State
Quality-Related
Outcomes
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Functional Health State
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Quality-Related
Outcomes
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Perception of Overall Health and Quality of Life
Health State
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MEASUREMENT PARAMETERS
Symptom Relief/Management
1. Oxygenation
2. Fluid/Electrolyte
3. Sleep
4. Nutrition
5. Comfort/Pain
6. Elimination
7. Safety
Individual adaptive processes/coping skills
Family adaptive processes/coping skills
Aggression level
Mental status
Self care abilities/disabilities and Activities
of Daily Living (ADL’s) and Instrumental
Activities of Daily Living (IADL’s)
Compliance with therapeutic regimen
Individual role Function: work, school,
parent, patient
Interpersonal/Sexual/Social function
Family/Caregiver functioning
Community functioning
What influence does the altered health state
have on the client’s (individual, family,
group, community) overall view of
his/her/their present health and overall
ability to function?
How does the client (individual, family,
group, community) compare his/her/their
physical and/or mental health at present
with his/her/their health in the recent
past (can put a time frame?)
How does the client (individual, family,
community, group) see his overall mental or
physical health status in the future? What
understanding does the client have of his/her
illness and the potential impact of illness on
his/her quality of life and lifestyle? How
would the client (individual, family, group,
community) rank the influence of
his/her/their present health state on his/her
quality of life?
Has the client’s (individual, family, group,
community) quality of life changed over the
past ________ weeks (months/years)?
Is this change secondary to the change in
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Cost-Related
Outcomes
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Financial Health State
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health?
Cost Factors (actual cost of care compared
to average costs of care for general
population experiencing the change in
health status)
LOS compared to ELOS (when applicable)
Productivity costs (missed work, school)
ER visits
# of home/clinic visits
Cost to the community
When formulating expected outcomes, keep the following in mind:
1. These outcomes are those that are commonly expected when managing the disease for a specific
population.
2. These outcomes are NOT related to or individualized to the specific client; they relate to the
anticipated or desired responses to managing the disease.
3. Expected outcomes are based on the results of practice and the clinical and research-related literature.
When identifying expected outcomes for the disease or health alterations encountered by the
individual client, family, or group; the literature, which includes your text, articles, or critical
pathways (if available) must be consulted in order to accurately identify the key expected outcomes
for managing the disease.
Desired Population Outcome Examples:
Clinical Outcome: Adolescents with Cystic Fibrosis (CF) will consume adequate calories (10% above
the RDA for adolescents without CF), consume the recommended amount of Vitamin D and K, and
consume calcium intake that meets the recommendations for age to minimize the incidence of osteopenia.
Quality Outcome: Adolescents with Cystic Fibrosis will participate in extra-curricular school activities
while maintaining adherence to their pulmonary treatment regimens.
Cost-related Outcome: Adolescents with Cystic Fibrosis will adhere to their pulmonary treatment
regimens to reduce the cost experienced with in-patient hospitalizations.
III.
Patient Profile
After identifying the expected population outcomes, you must assess your client, family, group, or
community in order to determine the status of your client in relation to the expected outcomes. Part of this
assessment includes the patient profile. The patient profile should “tell the story” of the client or
community. Subsequent care providers should be able to “know” the client just by reading the patient
profile. The patient profile should contain the following information:
 Age, gender, & ethnicity of patient
 Admission date
 Reason for admission [HPI]
 Medical/Surgical history [all past medical diagnoses, procedures]
 Significant events since admission (surgeries, procedures[intubation, extubation, central
line placement], and any complications
 Current status [i.e. How is the patient doing now?]
 Current invasive lines, equipment, IVs, therapies being used, etc.
 Allergies
 DNR Status
 Immunization Status
 Developmental Status
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This format will help guide the presentation of the client’s data in the patient profile.
Age, ethnicity, sex, whose primary language is _____, admitted on date for
________________________. The patient is or is not on isolation. Prior to admission ________.
Currently, the patient _____________. Past Medical history of ______________________________.
Development is appropriate of age or delayed. Allergies________ Immunizations ______DNR status
(unknown is an OK answer here)
Safety/Social concerns include __________.
Example:
Pt. is a 2 month old, Hispanic, previously healthy, male, whose primary language is Spanish, admitted
2/24/11 for cough and anorexia. The patient is in contact/droplet isolation for presumptive diagnosis of
RSV Bronchiolitis. Three days prior to admission, mother reports the child started with upper respiratory
symptoms characterized by a wet sounding cough, which is worse at night. On the day of admission the
baby was having difficulty feeding and breathing. Was using accessory muscles and required
supplemental oxygen per ER records. Currently the patient is in room air with appropriate oxygen
saturations but continues to require gavage feeds due to increased respiratory rate. Past Medical History:
born at 38 weeks gestation, normal vaginal delivery. Development is appropriate for age. Patient tracking
and cooing. NKDA, Immunizations UTD, DNR status unknown. Safety concerns for keeping crib side
rails up at all times to avoid a fall. Mother is involved in patient care and requires Spanish interpretive
services for medical communication. Mother does speak some English.
IV.
Patient Assessment Data and Variances
Determine which assessment categories are necessary in order to complete a comprehensive, yet
realistic assessment. This may mean that assessments that would be appropriate in the restoration
phase may not be appropriate for the health promotion phase. Check the assessment categories that
are appropriate. The following defines the general assessment categories on the care management
process.
A. Health: Includes health history, symptom history, physical examination, examination of mental
status, as well as an assessment for risk factors that predispose a person to disease or health
alterations. This assessment category can include screening or administration of a simple test that
identifies the variables that distinguish those individuals who most likely have or will have the
condition from those who do not. The nurse needs to be aware of health parameters and disease
state symptoms and how to obtain an accurate and useful symptom history. Symptoms are very
subjective and can vary widely. They are determined through an interview and health assessment.
In order to do an appropriate symptom history, the nurse must understand the disorder and its
manifesting signs and symptoms.
B. Diagnostic Tests: Objective formal tests used to identify disease and facilitate medical treatments
(e.g. CBC, EKG MRI, etc.).
C. Personal Values, Beliefs, Thoughts, Emotions, Behaviors: Examines beliefs, perceptions, and
values that are essential components of a client’s health and health behaviors. Can also include
developmental assessments, standardized personality/behavioral assessments, as well as
psychosocial, cultural, and spiritual assessments. Here, the care manager can also make
assessments about the client’s perceptions of his/her own health status, quality of life, and impact
of disease or health alterations on the client’s perceived health status, general lifestyle, and quality
of life. This assessment category can also include an examination of behavioral traits and
attitudinal characteristics by which we are recognized as individuals.
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D. Functional Assessment: Looks at general lifestyle and patterns of health behaviors and
management, role performance, and how the client performs and maintains Activities of Daily
Living (ADL's) and Independent Activities of Daily Living (IADL's). This assessment helps the
nurse to examine the functional level of the person and the impact that illness has on this
functional level.
E. Family/Social Support: In the new health care delivery model, the family is critical to the
ongoing care of the client. Understanding the dynamics of the family and the social support
network of the client—either through a formal interview of the use of a standardized assessment
tool—is very important to managing the care of the client within the social network of the client.
Family assessments are used to determine the structure, roles, communication pattern, coping
skills, knowledge base, rules of the family, and the impact of illness upon the family dynamics.
Assessments of the social support network of the client will help the nurse to understand the
strengths and limitations of the client’s social network in order to utilize the care management
process more effectively and enhance the quality of life for that client.
F. Environmental: There is a need to assess the physical and psychological environment where care
is delivered. The physical environment includes the setting, physical boundaries, odors, sound,
space, climate; psychological environment refers to issues related to privacy, openness in
communication, general rules of communication, noise levels. Risk factors for injury in the client’s
environment should also be assessed.
G. Resources (Community and Financial): There is a need to look at resources available in the
community that could be utilized to support the client’s optimal level of functioning. The nurse
must know your community resources and/or services offered, contact persons, and program
eligibility criteria in order to make timely and appropriate referrals. The structure, function, and
process of a community should also be assessed when caring for a population. Resources in the
community that could be utilized to support the client’s functioning should also be utilized. At the
same time, the client’s financial resources to meet socioeconomic and health care needs also
should be examined.
Some of the assessments may be based on standardized tools (e.g. Denver Developmental II, Simpson
Neurological Scale). Please identify the specific tools, as appropriate.
**Because faculty must be able to assess your ability to conduct appropriate assessments, some
faculty will have you attach the findings of the assessments and some faculty may quiz you on the
assessments. Therefore, you must be familiar with the purposes of your selected assessment tools as
well as the information you expect to obtain from the use of these tools. You also must be able to
conduct the assessments and understand the results of your assessment findings. Do not merely
provide a lengthy list of assessment tools, rather discuss the selected validity in assessing the desired
parameter of the identified patient population.
**An assessment tools packet is available on the course web site. This packet is not exhaustive, nor
does it replace the use of articles and texts as a source for assessments. It merely provides an added
resource and index for some of the most common assessment tools and where they may be found.
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Assessment Category Examples: “Assessments gather data”
V.
ASSESSMENT
CATEGORY
Examples of Assessment Category
(Provide Rationales and Citations in Parentheses)
HEALTH
(including risk factors, history,
physical examination, mental
status)
Vital Signs Q 4 hours
Breath Sounds Q 4 hours
24 hour Dietary Recall
DIAGNOSTIC TESTS
(e.g. laboratory, radiologic tests)
Basic Metabolic Panel Q Monday and Thursday
Pulmonary Function Tests Q Monday and Thursday
CXR Q Monday
PERSONAL VALUES, BELIEFS,
THOUGHTS, EMOTIONS,
BEHAVIORS
(e.g. developmental, psycho-socialcultural-spiritual, health perception,
QOL)
Perform the Denver II prior to discharge
FUNCTIONAL
(ADL, IADL, general role
performance)
Assess incorporation of treatment regimen into ADLs
FAMILY/SOCIAL SUPPORT
Assess family support system
ENVIRONMENTAL
(environment where care is being
received and/or where client will
return)
Assess teacher’s knowledge of Cystic Fibrosis and their willingness to allow
frequent bathroom breaks.
RESOURCES: Financial
and Community
Assess financial resources and qualifications for acquisition of pancreatic
enzymes
Analysis and Determination of a Client Variance after Assessments
An analysis requires an ability to think through the data and integrate theory in order to interpret findings
and draw conclusions so that appropriate management strategies and interventions can be implemented.
The analysis consists of three parts:
1. Client variance after assessment,
2. Individualized Nursing diagnosis and problem identification, and
3. Individualized Client-specific outcomes.
A. Client Variance is defined as any deviation from the expected. The analysis will determine
whether the findings from the specific client’s assessment deviate from the expected outcomes
from the population and will assist in formulating the Nursing Diagnoses. Other factors, ie
other illnesses, interpersonal variables, financial variables, environmental variables, may
contribute to the variance OR influence the client’s health state. To determine if a variance
exists ask the following questions:
 How does my client compare to the expected population outcomes? If there are no
variances between the clients’ Health State and the expected population outcome,
acknowledge this (e.g. “No variance”).
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What other factors might be impacting the client’s health state? Other illnesses,
interpersonal variables, financial variables, variables, environmental variables?
What is the PRIORITY nursing diagnoses?
If there are variances between the expected outcomes and the client’s health state:
 Describe these variances and
 Describes any factors (e.g. co-morbid illnesses, treatment complication, etc.) that may
be responsible for the variance. This is important as it may impact the care delivered to
the client. Variables impacting the variances must be addressed in this section. Also,
this is an area where readings and other pertinent classroom material should be
integrated.
B. Individualized Nursing Diagnoses and Problem Identification: Disease management
involves understanding and treating the disease across populations and across the continuum
of care. Care management focuses on the individual client, family, group, or community in the
context of the disease. Human responses are the focus of care management. Nursing diagnoses
emphasizes the nurse’s interpretation of the variances and formulation of diagnoses that reflect
the human response to the disease. The nurse must be able to identify variance and human
response as they impact, and often, alter the course of managing the disease. Research may
exist to manage a disease; however, no disease is ever ideally managed since the human
dimension makes any disease context more variable.
1. After you identify variances you are to categorize the variances into nursing diagnoses
(using one of the 5 above categories)??? What 5 cagories?? Health states??? that
reflect the response of your client, family, group, or community.
2. Use the PES format to formulate the nursing diagnoses.
True Nursing Diagnoses Includes:
Problem: Describes the response of the client (diagnostic label [NANDA, IOWA
system], descriptive phrase).
Etiology: Factors contributing to the problem (Should incorporate Pathophysiology,
treatment, meds, situation)
Symptoms: Defining client symptoms/characteristics that substantiate the diagnostic
label (Both subjective and Objective data)
“At Risk For” Nursing Diagnoses Includes:
Problem: Describes the response of the client (diagnostic label)
Etiology: Factors contributing to the problem (Should incorporate Pathophysiology)
Symptoms: NOT included as the client has yet to exhibit the symptoms/defining
characteristics to make it a TRUE nursing diagnoses, ie. the problem has not occurred.
Nursing Diagnoses Examples:
True Nursing diagnosis:
P: Ineffective Airway Clearance
E: Related to excessive production of thick mucous and decreased ciliary action due to
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defective CFTR protein
S: As evidenced by decreased breath sounds in lower lobes bilaterally, declining
pulmonary function tests, ineffective cough, and patient stating “I just can’t take a deep
breath”
“At Risk for” Nursing diagnosis:
P: At risk for aspiration
E: Related to poor tracheobronchial passage protection from reduced level of
consciousness with anesthesia
S: (Left blank as client has not demonstrated any symptoms)
C. Individualized Client-specific Outcomes: After identifying the nursing diagnoses, specific
client outcomes are formulated. These provide direction for nursing care management. These
specific client outcomes facilitate an understanding of the client’s responses and needs in
relation to the population-based disease management outcomes. This helps to individualize
care while continuing to use best practice guidelines and protocols established for diseases as
cited in the literature.
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The outcomes must be “SMART”:
Specific: Client-centered (patient or community): Outcomes communicate expected
behavior and an expected response for the individual client who is receiving the care
during a specific time frame.
Measurable: Able to quantify (objectively/subjectively) to determine if outcomes
achieved
Achievable:
Realistic:
Time-sensitive: To facilitate deliberate, efficient patient care.
Individualized “SMART” Outcome Example:
The client will provide a return demonstration of appropriate meter-dosed inhaler use by
the second day of hospitalization.
The client will gain 10-30 grams/day during his hospitalization.
VI. Intervention Categories
1. Intervention strategies and categories must be determined to provide comprehensive, yet realistic,
cost-effective care. This may mean that interventions that would be appropriate in health promotion
may not be appropriate in restoration
2. When utilizing the Care Management Process tool, identify and prioritize the intervention categories
that are appropriate. The following defines the general intervention categories in the care management
process.
A. Therapeutic Symptom Management and Morbidity Reduction: Knowledge regarding the
the natural course of a disease, will assist the nurse with timely, and effective symptom
identification to determine and initiate the most appropriate interventions to manage these
symptoms. The client’s symptoms and/or specific health problems should be clearly identified.
B. Medication Management: Goes beyond just administering medications. It also includes the
nurse’s role in client education, monitoring, and compliance.
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C. Skills and Technologies: Includes psychomotor/technical skills with machines for client
diagnostic and monitoring purposes as well as communication skills and informatics or use of
computer technology to manage data and/or provide care.
D. Social/Behavioral Interventions: This intervention refers to building and utilizing
collaborative relationships with clients. The client is most knowledgeable about his/her
behavior, response to illness, and lifestyle. The nurse will need to utilize the client’s input
about himself or herself in care management. Partnerships and mutual goal setting are essential
for behavior change and disease prevention and management. Interventions in this category
can be in the form of a therapeutic nurse-client relationship, advocacy, problem-solving
models, group therapy, negotiation, conflict resolution, etc.
E. Family/Caregiver Support and Education: Interventions which utilize community education
programs, social support networks, home health and related agencies, concepts of family
nursing. This category of interventions can provide emotional and physical support to
caregivers at home to reduce the potential for caregiver burden and role strain. Education
about the client’s medication and treatment regimen is also included in this category.
F. Client Education: Includes using teaching-learning strategies to provide information and
increase one’s awareness so as to enhance one’s decision-making. This category is critical to
promoting change in health behavior and lifestyle.
G. Referrals: Includes making timely, cost-effective, and appropriate referrals to members of the
multidisciplinary team, community, as well as local, state, and national resources. When
making referrals, the care manager must use a systematic, problem-solving process that builds
on the client’s strengths but recognizes the limitations of the client and seeks to meet the
client’s needs as quickly and cost-effectively as possible. In order to do this, the care manager
must be aware of the community’s resources, how to find appropriate community resources,
and the eligibility criteria for particular programs or resources.
H. Community Support and Education: This is a category of interventions that supports—and
works with—the community’s structure, process, and functioning. The concept of community
as client is crucial to the care manager’s ability to function as a community advocate and
facilitate ongoing health-promoting changes in the community. The care manager is expected
to apply concepts of population-based care, partnership, relationship-building, empowerment,
and change process when caring for a community. A variety of group teaching-learning
strategies and communication skills can be utilized to improve the health of the entire
community.
3.
4.
The “expected care management strategy” column is designed for the identification of practices that
have been identified as commonly used in managing the disease. They may often be broad in nature
and multidisciplinary in scope. They tend to identify the broad areas of care that must be
accomplished to effectively manage a disease across populations and the care continuum. All care
management strategies must be derived from your texts, articles, or critical pathways. Rationales
should be provided for the interventions. Instructors may want rationales written or told to
him/her verbally.
The type of strategy column helps to identify the nature of the strategy in terms of its placement on
the continuum of care despite the care setting. The type of strategy indicates the level of health care
delivery the client is receiving. These interventions are provided along a continuum of care and are
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not specific to the care setting. For example, a skills and technology intervention such as obtaining
blood pressures, may be performed in the home setting or in an intensive care unit. The type of
strategy (health promotion, health protection, health restoration, or health maintenance) is the
identifier that indicates the level of health care delivery the client is receiving. Thus, blood
pressuring monitoring in the acute care setting may indicate a health restoration strategy if the client
was admitted for symptoms related to a hypertensive crisis; whereas, blood pressure monitoring in
the home care setting may indicate health maintenance for patients who are checking their blood
pressure twice a week and prn to ensure their hypertensive medications are appropriate and they
remain in a symptom free state. This example illustrates that interventions may actually serve
multiple purposes (both promotion and protection or restoration and maintenance).
5.
Explanation of each strategy is as follows:
A. Health Promotion strategies are aimed at lifestyle and behavior changes and generally
involve formal or informal educational approaches (education about smoking cessation, diet,
exercise, etc.)
B. Health Protection strategies are interventions that are more invasive but still protective in
nature (immunization, fluoride water treatment, use of protective clothing or equipment in the
work setting, etc.).
C. Health Restoration strategies aim to restore the client from a symptomatic state to an
asymptomatic and optimally functional state (initiating insulin treatment and diabetic teaching,
surgery, wound care, IV and/or medication therapy, etc.). The client at this point is usually
receiving care in an acute care, primary care, or home health care setting.
D. Health Maintenance strategies aim to maintain the client in an optimally functional and
symptom-free state (cardiac rehabilitation program, blood glucose screening at home twice a
day instead of four times a day in the hospital, etc.). Place a  in the appropriate descriptor for
the care management strategy. Some interventions may actually serve multiple purposes (both
promotion and protection or restoration and maintenance).
VII. Collaborative/Interdisciplinary Communication
Examine the need for Collaborative/Interdisciplinary Communication and Coordination. As a care
manager, it is necessary to work together with a variety of other disciplines in order to meet the overall
outcomes of care. The nurse will need to be able to clarify and provide information, initiate discussion,
encourage others to participate, and build consensus as well as recognize—and correct—when members
are hindering group discussion. Skills in group process, conflict resolution, team building, negotiation,
delegation, and communication are essential in this area. Building community contacts and networks are
critical to collaboration and knowing when it is necessary to request a consult, team meeting, or referral.
A basic knowledge of health care economics and health care policy will also be fundamental to effective
collaboration. Determine if - and with whom - collaboration is essential to the effective management of
this client’s care. Specify the purpose - and the results - of the contact. Again, the nurse may need to
research community resources re: eligibility criteria, services offered knowledgeable contacts, etc. for
optimal collaboration.
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VIII. Outcomes Quality-Cost Evaluation/Variance Analysis
At times the expected outcomes associated with disease management are not met. Also, the expected
strategies used to manage a disease cannot be used with individual clients. This section requires the nurse
to compare the differences between the expected outcomes and care management strategies and the actual
interventions and client outcomes.
Variance can be positive or negative. A positive variance occurs when the outcome improves more
quickly than expected or above expected standards. Negative variance occurs when outcomes become
worse or the interventions are not successful.
Steps in Evaluation/Variance Analysis
1. Identify the expected outcomes (do not rewrite all outcomes—use numbers)
2. Mark if the outcome is “Improved”, “No Change”, or “Worsens”.
3. Explain any variance that occurred-especially if there was a negative variance. If there was a
positive variance, please note the potential reasons for this variance.
4. Identify the possible causes of the variance. These causes may be client-related, care-related or
system-related.
A. Client-related: changes in physiological status, changes in emotional status, nonadherence with treatment, unmet clinical outcomes through no one’s fault;
B. Care-related: Refers to any situation in which the health car provider causes the delay
e.g., delay in initiating diagnostics, treatments, meds, poor discharge planning,
inappropriate referrals or lack of necessary referrals/coordination among the disciplines;
C. System-related: Equipment problems, inefficient scheduling, access problems, financial
factors
5. Based on the variance analysis, note recommendations/actions (i.e., new strategies, modified
strategies) that should be taken to correct negative variance or further positive variances.
(Original strategies can also be updated as necessary). Be prepared to discuss
recommendations if necessary.
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