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Case Management - Coggle Diagram
Case Management
P05: Principles of Strength Perspective & Transitional Care Panning
Every Individual, group, family, and community has strengths. The strength perspective is to identify these strengths and resources.
Trauma and abuse, illness and struggle, may be injurious but they may also be sources of challenge and opportunity. Hence, we can help clients to focus on their growth and opportunities in such events.
Assume that you do not know the upper limits of the capacity to grow and change. Take individual, group and community aspirations seriously. This principle means workers need to hold high the expectations of their clients and from alliances with their hopes and values.
We best serve clients by collaborating with them. A helper is more effective as a collaborator than an expert and from alliances with their hopes and values.
Every environment is full of resources. The strength perspectives focuses in a sense, also in caretaking, since this is related to hope.
Sources of Strength
What people have learned about themselves and others
Personal qualities, traits and virtues
What people know about the world around them
Talents people have
The community and spiritually, pride
Transitional Care Planning
A client centered interdisciplinary process that begins with an initial assessment of the client's potential needs at the time of admission and continues throughout the client's stay.
Coleman's Model
Medication Self-Management
Dynamic Patient-Centered Record
Follow-Up
Red Flags
P04: Biopsychosocial issues of ageing
Geriatrics
The process of ageing is a continuum progressing throughout the individual's life.
Psychologic aging in any given individual may occur more rapidly or slowly than the chronologic age, giving rise to people who are "old" at age 60 & other who are young at age 75.
Geriatric medicine deals with problems and diseases of old age
A process that's genetically programmed but modified by environmental influences, so the rate of aging can very widely among people.
Definition:
Chronological Age: or number of years.
Biological Age: changes reducing efficiency of organ systems
Psychological Age: including memory, adaptive capacity, personality mental functioning
Social Age: social roles, relationship and overall context in which we grow old.
Psychological Problems with Aging
System:
Cardiovascular
Haematological and Immune
Respiratory
Gastrointestinal
Genitourinary
Endocrine
Neurological
Eyes and Ears
Musculoskeletal, Dermatological
Changes in Mental State
A great deal of elder assessment depends on the assessment of a person's mental state to some degree. Changes in mental status can be very subtle and often go unrecognized.
Case Mangers who work with geriatric patients should familiarize with different causes of risk factors relating to cognitive decline such as:
Dementia
Depression
Social Isolation
Agitation or Aggressive Behaviour
Injuries such as falls and burns
Nutritional deficits and fluid and electrolyte disturbances infections
Non-adherence to treatment plans or medication, or both
Cognitive Functions which elderly people commonly have difficulty with include:
Orientation (eg. time and place)
Memory (eg. registration and recall)
Attention and Calculation (eg. counting back)
Language (eg. naming an object, reading, writing, following complex command, visual-spacial perception)
Common things in elderly people:
Urinary Incontinence
Fall
Elder Abuse
Elder Depression
P01: Introduction to Case Management
What is Case Management
Case Management is a collaborative process that utilizes a comprehensive and holistic assessment to identify needs, coordinate services , educate, advocate and empower clients and their support systems with the aim of enabling them to remain in the appropriate care setting and achieving optimal care and cost-effective outcomes
Purpose of Case Management
To determine an individualized service plan for each client and monitoring that plan to be sure it is effective
A process used to ensure that the money being spent for the client's services is being spent wisely and in the most efficient manner
What is a Case Manager?
A person from the healthcare and allied health profession.
Coordinate the process, collaborates with the client, caregivers and key service providers to ensure that the plan is developed appropriately
Steps of The Case Management Process
Client Identification/ Selection
Assessment of Client
Development & Implementation of Plan of Care
Coordination of Services
Evaluation of case management plan and services
Closure of Case Management services and process
P09: Service Planning & Implementation
Care Planning
Prioritise the patient's need
Determine the services required to attain the established goals
Establish goals of Treatment
Document the process
Advanced Care Planning
Process that states patient's care preferences and treatment
Benefits:
Identify a nominated healthcare spokesperson
Guide physicians to make treatment decisions
Reduce burden and distress on family
Social & Public Assistance Scheme
Merdeka Generation
Pioneer Generation
CHAS Cards
Caregiver Training Grant
Senior Mobility & Enabling Fund
Advanced Medical Direction
Legal document signed in advanced to inform doctors that you do not want to use any life-sustaining treatment to prolong life when you become terminally ill and unconscious and where death is imminent
P07: Practice of assessment
what are the components of an eco-map and genogram?
genogram is a pictorial display of a personal family relationship and medical history
ecomap is a diagram that shows the social and personal relationship with the individual's environment
micro, meso and macro aspect affects the individual support system and the type of intervention
micro= individual factors
meso= physical, socio-cultural and community environments
macro= policies and government
The 3m's contribute to the factors that influence the individual's behavioural change
ecological model to analyse individual, family and societal factors that influence the change in behaviour
The model considers the interplay within the individual relationship, community and societal factors, how one factor influence other factors at another level
Components of geriatric assessment
includes the medical assessment, assessment of functioning, psychological assessment, social assessment and environmental assessment
to show if the individual is at risk of declining health or at risk of fatality
It also goes beyond the clinical diagnosis which looks at the adult as a whole
to obtain the functional performance of the adult
Link Title
P02: Regulatory Environment of Social Service Organizations
The Social Service Sector
Voluntary Welfare Organization (VWO) also known as social service organization (SSO)
A social service organization is a non-profit organization that provides services to benefit the community and caters for those in need or at risk
Key Areas in Social Service
Mental Health - assist them in their recovery journey in regaining psychosocial and functional skills
Children and Youths - help them develop the skills they need to meet and overcome life challenges
Families - providing them with resources they need to gain self patience and successfully function in society
Seniors - enabling them to stay healthy, socially engaged and cognitively intact so they can age with dignity
Disabilities and Special Needs - give them opportunities to reach their potential and be included in the community
What are charities?
They are organizations that operate on a not-for-profit basis, set up exclusively for charitable purposes and carry out activities which benefit the public
Sections of Code of Governence
Board Governance, conflict of interest, strategic planning, programme management, human resource management, financial management and controls, fund-raising practices, disclosure and transparency, public image
P06: H0ME VISIT
Objectives
Understand the pre-morbid or existing living pattern
identify issues that affects the client's ADL and IADL
Observe family dynamics and support
Manage the person, not the disease
Pre-Home Visit
Pre-Arrangement
Best time to visit
Client's notes, forms and equipments
Staff Safety
Seek clearance/approval for visit from management
During Home Visit
Respect cultures
Introduce and state your purpose for visit
Conduct Holistic Assessment
Medical
Functional
Psychological
Environmental
Client
Knowledge of condition and medication
Strengths and Risks
Current Health Status
Adherence to treatments and medications
Post Home Visit
Complete Documentation of the visit
Write future visits in planner
Check-In or do a follow up through calls
Ask supervisor or other colleagues regarding questions
P12:Models of care
the different models and approaches
mental health services in the community
institute of mental health
day care rehabilitation centre (dementia day care centre, psychiatric day care centre)
home visit (assess and counsel)
CREST (community resource engagement and support team)
types of client served between the community mental health case management models
the services available to support the infirm and caregivers in the community
brokerage model
assertive community treatment model
strengths model
clinical model
behavioural health case management
strategy for delivery of health care services to all persons with behavioural health disorders
P03: Roles and Competencies of Workers in Case Management
Competencies of Case Management
Assessing the client's ,medical, physical, cognitive, economic & emotional strengths and abilities as well as their available support system
Ongoing collaboration between the client, family and the service providers in the community to provide the valuable link which facilitates the process of informed decision-making
Work in partnership with clients and families on the various range of service and options available in the community
Competencies of Case Manager
Communication skills
Interpersonal skills
Organizational skills
Service Coordination skills
Advocacy skills
Teaching skills
Knowledge base about the community, health issues and available services
Personal Characteristics
Sensitivity - aware and truly respect the experience, culture, feelings and opinions of others
Trust Worthiness - being honest, allowing others to confide in you, maintaining confidentiality and upholding professional ethics
Open Mindedness - willingness to embrace other differences including their flaws, be non-judgmental in your interactions
Objectivity - striving to work and view clients and their circumstances without the influence of personal prejudice or bias
Interpersonal skills - ability to listen, care and respond to clients and communities with compassion and kindness
Competence - develop the knowledge and skills to provide quality service
Commitment to Social Justice - heart to fight injustice
Good psychological health - mental and emotional capacity to perform your work professionaly
Self awareness and understanding - willing and bale to reflect upon your own experiences
P11; Types of Mental Health Disorder
common mental health disorder
depression
alcohol abuse
bipolar disorder
schizophrenia
obsessive compulsive disorder
strategies to manage the mental health disorder
medication
psychotherapy
educate the patients and their family members on the condition of the patients, so that they are well aware and know how to manage it
Having a treatment plan
Training in social skills and community based living
challenges in community mental health case disorders in the community
face difficulty in making a diagnosis
dual diagnosis, patient taking cocaine to relive the symptoms of depression
potential abuse of certain medication such as anxiolytic
nicotine dependent
P10: Roles and Responsibilities of Mental Health Care Workers
Inpatient hospital
Integrating, coordinating and advocating for complex mental and physical healthcare services from a variety of healthcare providers and settings, even after hospitalisation
Often accountable for the welfare of the patient during the hospitalisation and providers support for the patient and family members/caregivers while moving the patient towards a timely discharge
Partnering with hospital staff during unanticipated hospital stays
Understanding and incoporating the hospital's care pathway in the case management practice
Partial Hospitalisation
Facilitating access for emergency treatment
Provide support and education for patients and family members/caregivers
Develop and implement patient-centered aftercare plan
Ambulatory Care
Patient and Family education
Counselling
Encouragement of adherence to regimen
Crisis Intervention
Maintenance of follow up care
P08: Practice of Assessment (Part 3)
Resident Assessment Form (RAF)
Introduced by MOH and widely used to determine elegibility for admission to subsidised nursing home care
One page form scoring on 9 parameters
EG:
mobility
feeding
toileting
hygiene
social
emotional
behavioural
InterRAI Home Care Assessment Form
International tool introduced to Singapore in 2011
and is only used by trained assessors
Focuses on the person functioning and quality of life by assessing needs, strengths and preferences
Clinical assessment protocols (CAPs) contain general guidelines for further assessment and individualized care and services
Single standardized assessment required to provide a standardize language of assessment across hospitals and community
There are 30 CAPs in multiple domains (clinical, mental health, psychosocial and physical function)
On average, a person receiving home care services triggers about 10 out of 30 CAPs
Types of needs assessment tolls used locally
Right service, Right Patient, Right Setting
Care assessment tools are used by only trained assessors
Piloted by AIC in collaboration with the MOH in the hospital and nursing homes
Validated tool across different countries