Case Management Guide to Population Health: Management Across the Continuum of Care

Mary McLaughlin-Davis, DNP, MSN, NEA-BC, APRN-BC, CCM

Dramatic changes are occurring in healthcare as pay-for-quality and performance improvement continue to drive innovations in care delivery. One of the changes that is fast becoming a critical outcomes driver for provider organizations is population health management. While this new model has been demonstrably effective at achieving better patient outcomes at a lower cost, case managers need resources and guidance on how to approach an overhaul to their program.

Case Management Guide to Population Health: Management Across the Continuum of Care is a comprehensive playbook for ensuring the effectiveness of a population health program. This resource is designed to help case management and other healthcare professionals examine social determinants of population health, gauge the sustainability of population health modules in case management, and measure case management outcomes.

Authored by Case Management Society of America President Mary McLaughlin-Davis, this book offers personalized insight into the history of case management and the population health evolution in addition to providing factual guidance for the future from a respected case management authority.

This book will help you:

• Assess your readiness to transition to population health
• Identify key stakeholders in population health initiatives 
• Identify the five social determinants of population health
• Explain how patient preferences and choices are centric to population health
• Implement a process improvement strategy to include case management into a population health initiative
• Learn how to get critical members staff on board with the program

About the Author:

Mary McLaughlin-Davis, DNP, MSN, NEA-BC, APRN-BC, CCM, is national president for the Case Management Society of America (CMSA) and is an active member of CMSA’s Public Policy Committee. Davis is a senior director of care management for the Cleveland Clinic Health System and an adjunct nursing faculty member at Ursuline College. She has provided care coordination services for inpatients, outpatients, and healthcare plans. As a clinical nurse specialist, Davis has worked extensively with patients having chronic disease, notably congestive heart failure and stroke.

Published: October 2017
Dimensions: 8.5 X 11
Page Count: 128
ISBN: 978-1-68308-497-6

Table of Contents:

1. Population Health: A Journey and a Destination for the Case Manager

a. Alternative payment models
b. Payer models
c. Public health model
d. Stakeholders and customers

2. Integrated Case Management

a. Definitions of case management
b. Case management for medical health
c. Standards of case management practice
d. Case management for behavioral health

3. The Case Manager’s Evolving Role

a. Historic
b. Curren

4. The Interprofessional Team

a. Interdisciplinary team members

5. The Case Manager Assistant

a. The distinction between the case manager and case manager assistant
b. Who is the case manager assistant?
c. Patient relationships with case managers and assistant

6. Social Determinants of Population Health

a. Defining health literacy
b. Impact of health literacy
c. Health literacy interventions
d. Financial security
e. Food and shelter
f. Transportation and access to the healthcare system
g. Patients, clients, and veterans at risk

7. Patient-Centric Care in the Population Health Model

a. Assessment
b. Motivational interviewing
c. Patient-centric goals
d. Patient activation and patient engagement
e. Significance to case managers

8. Transitions of Care

a. Hospital transitions
b. Care transition obstacles and interventions
c. Postacute care
d. Transitions home

9. Tools for the Case Manager

a. Standards of practice for case managers
b. Software programs for case managers

10. Measuring Case Management Outcomes

a. PHQ-9
b. Patient activation measures
c. HCAHPS
d. CAHPS
e. Readmissions

11. Sustainability of Managing a Population Health Model with Case Management

a. Plan, do, check, act
b. Kaizen process improvement
c. Visual tools
d. Standards of practice
e. Standard professional responsibilities and scholarship
f. Dissemination and sustainability