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| Communication Basics - Case Management Basics |
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| INTRODUCTION |
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There are multiple definitions of case management that are both health discipline specific and
open to interpretation. This module will outline various models of cardiac rehabilitation and
provide one definition of the case management process.
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| LEARNING OBJECTIVES |
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THE LEARNER WILL BE ABLE TO:
- Demonstrate an understanding of case management within traditional and alternate cardiac rehab program models
- Design a case management strategy for a given patient population
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| CONTENT |
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- Chronic Disease Management
Cardiac Rehabilitation, whether administered through on-site or home based programs is a
chronic disease management program. Chronic disease management using the Chronic Care
Management Model is a philosophy of care involving interactions between the health system
and community that ultimately leads to a prepared proactive team having productive
interaction with informed activated patients resulting in improved care outcomes
Cardiac Rehabilitation Program Models: Traditional, Alternative, Case Managed & Managed Care
The Canadian Association of Cardiac Rehabilitation (CACR) has defined various cardiac
rehabilitation programming as traditional, alternative, case managed or interventional
managed care models. Not all patients fit into nor require one type of cardiac
rehabilitation program model. Various service delivery models have been identified
and many programs have begun to combine models to optimize care and
improve resource utilization. These include inpatient, outpatient,
facility-based, home-based and alternatives such as internet-based programs
for patients in remote areas or areas where CR services are not available.
- Traditional Cardiac Rehabilitation Model
- Alternative Program Model
- Case Management Model
- Managed Care Model
Traditional Cardiac Rehabilitation Model
Currently, most so-called traditional programs are comprehensive in nature. Care services
include patient education with respect to disease processes, risk factor modification
and stress management, psychosocial assessment and counselling, vocational counselling,
and dietary counselling. In this model of cardiac rehabilitation, patients are most frequently
referred by their family doctor or cardiovascular specialist for supervised exercise and
cardiac education following an acute cardiovascular event. Although risk factor abnormalities
are usually identified and suggestions made regarding the management provided, the actual
medical intervention and prescription of medications is most often left to the patient’s primary
care physicians and/or specialist. Increasingly these types of programs are combined with case
managed or managed care programs.2
Alternative Program Model
Alternative programs such as home based (individual) programs are an alternative to facility
based group exercise programs. Home based programs utilize limited hospital or clinic
visits with regular mail or telephone or internet based follow up by a case manager,
usually a cardiovascular nurse or nurse practitioner. Within home based cardiac rehab (CR)
programs, the case manager usually provides ongoing communication to facilitate risk
factor modification and interfaces directly with primary care physicians, specialist
physicians and the multidisciplinary cardiac rehabilitation team.
Recent research has shown that patients attending home based cardiac rehabilitation
programs experience similar exercise capacity, quality of life, lower blood lipids
and smoking cessation benefits when compared to traditional model and may also be suited
to low risk patients who may not want, nor require, a group exercise experience.
Case Management Model
In case management models, a case manager coordinates the activities of various health-care
disciplines, on behalf of the patient. The case manager, working with a series of treatment
protocols or treatment decision algorithms, is empowered to initiate or adjust medications for
cardiovascular disease (CVD) risk factors. This care model has been shown to be significantly
more effective than usual care models, such as usual physician care, in both smoking cessation
and cholesterol reduction. The case management model of patients with CVD may well be ideal for
many cardiac rehabilitation programs. The concept can be aligned very effectively with both
traditional and home based models to enhance service delivery and improve patient outcomes.
Managed Care Model
Managed care, also referred to as Interventional care, cardiac rehab programs embrace all of
the key components necessary for the provision of comprehensive cardiac rehabilitation services
but assume a more direct, hands-on approach to risk factor modification. Thus, within interventional
CR programs, the regular monitoring of treatment targets during the program facilitates the timely
modification of treatment approaches and prescriptions by cardiac rehabilitation physicians.
- 2004 CACR Guidelines pages 230-231 & 2009 CACR Guidelines pages 389-399
- Review
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| LEARNING ACTIVITIES |
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Review Leonard Patrick’s case history
Check Answer
- Using the same case study
- Have a colleague role play the part of Leonard Patrick
- Using behaviour change, motivational interviewing and coaching processes create dialogue to help Leonard establish short term and long term goals.
- How would you communicate your session in a letter to his primary care physician?
Check Answer
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| REFERENCES |
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- Stone JA, Arthur HM. Canadian Association of Cardiac Rehabilitation (2004) Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention: Enhancing the Science, Refining the Art. Second Edition.
- Taylor, R.S., Brown, A., Ebrahim, S., Jolliffe, J., Noorani, H., Rees, K., et al., (2004). Exercise- based rehabilitation for patient with coronary heart disease: Systematic review and met analysis of randomized control trials. American Journal of Medicine, 116(10), 682-692.
- DeBusk, R.F., Miller, N.H., Superko, H.R., Dennis, C.A., Thomas, R.J., Lew, H.T., et al., (1994 A case-management system for coronary risk factor modification after acute myocardial infarction. Annals of Internal Medicine, 120(9), 721-729.
- Jolly, K., Lip, G., Sandercock J., Greenfield, S., Raftery, J., Mant, J., Taylor, R., Lane, D., Lee, K., & Stevens, A. (2003). Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularization: design and rational of the Birmingham Rehabilitation Update Maximisation Study: a randomized controlled trial. BMC Cardiovascular Disorders, 3, 1 – 11.
- Marchionni, N., Fattirollis, F., Fumagalli, S., Oldridge, N., Lungo, D., Morosi, L., et al. (2003). Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized controlled trial. Circulation, 107, 2201-2206.
- Smith, K., Arthur, H., McKelvie, R., & Kodis, J. (2004). Differences in sustainability of exercise and health-related quality of life outcomes following home or hospital-based cardiac rehabilitation. European Journal of Cardiovascular Prevention and Rehabilitation, 11, 313-319.
- Arthur, H., Smith, K., Kodis, J., & McKelvie, R. (2002). A randomized controlled trial of hospital versus home-based exercise following coronary by-pass. Medicine and Science in Sports and Exercise, 34, 1544-15550.
- Stone J.A., Arthur H.M.(Eds) Canadian Association of Cardiac Rehabilitation (2009). Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention: Translating Knowledge into Action. Third edition.
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