Name of the Procedure:

Common Name: Targeted Case Management
Technical Term: T2023 - Targeted Case Management; per month

Summary

Targeted Case Management (TCM) involves the coordination and oversight of various healthcare services for individuals, especially those with chronic or complex conditions. The aim is to ensure that patients receive appropriate care and support through comprehensive case planning and management on a monthly basis.

Purpose

Medical Conditions:

• Chronic illnesses (e.g., diabetes, heart disease, COPD)
• Behavioral health issues (e.g., mental health disorders, substance use disorders)
• Disabilities (physical or developmental)
• Post-hospitalization

Goals:

• Streamlined access to healthcare services
• Improved patient health outcomes
• Reduced hospital readmission rates
• Enhanced patient quality of life

Indications

Symptoms/Conditions:

• Frequent hospitalizations or emergency room visits
• Difficulty managing chronic conditions
• Complex medical or psychosocial needs
• Lack of necessary resources or support systems

Patient Criteria:

• Individuals with a diagnosed chronic or complex condition
• Patients requiring continuous healthcare coordination
• Those who benefit from a structured, monthly review and planning

Preparation

Pre-procedure Instructions:

• No specific fasting or medication adjustments are needed.
• Patients may need to complete certain assessments or evaluations to determine eligibility.

Diagnostic Tests or Assessments:

• Medical and psychosocial evaluation
• Assessment of healthcare needs and goals

Procedure Description

Steps:

1. Initial Assessment: Comprehensive evaluation of the patient's medical, social, and environmental needs.
2. Care Planning: Development of a personalized care plan outlining required medical and support services.
3. Coordination: Regular communication with healthcare providers, arranging appointments, and managing referrals.
4. Monitoring: Continuous monitoring of patient progress and modifications to the care plan as needed.
5. Monthly Review: Evaluation and adjustment of the care plan on a monthly basis to align with changing needs.

Tools/Equipment:

• Electronic health records (EHR)
• Communication tools (phone, email, telehealth platforms)

Anesthesia/Sedation:

• Not applicable

Duration

How Long:

• Ongoing, with a formal review and update of the care plan at least once per month.

Setting

Where:

• Can be managed from various settings including:
  • Outpatient clinics
  • Primary care offices
  • Community health centers
  • Patient's home (via telehealth)

Personnel

Healthcare Professionals Involved:

• Case managers (e.g., nurses, social workers)
• Primary care physicians
• Specialists
• Behavioral health professionals
• Support staff (e.g., administrative assistants)

Risks and Complications

Common Risks:

• Miscommunication or information gaps with healthcare providers
• Potential delays in service coordination

Rare Risks:

• Confidentiality breaches
• Financial costs or lack of insurance coverage

Benefits

Expected Benefits:

• Improved management of chronic conditions
• Better coordination of healthcare services
• Enhanced satisfaction with care
• Reduced hospital admissions and emergency visits

Realization Timeline:

• Depending on the patient’s situation, benefits can start to be observed within a few months.

Recovery

Post-Procedure Care:

• Continuous monitoring and adjustment of the care plan.
• Regular check-ins with the case manager.

Expected Recovery Time:

• Not applicable, as this is an ongoing management service.

Restrictions/Follow-Up:

• Adherence to the care plan and attending scheduled healthcare appointments.

Alternatives

Other Treatment Options:

• Self-management of health conditions
• Use of standalone healthcare services without a coordinated plan

Pros and Cons:

• Self-Management
  • Pros: Increased autonomy; Cons: Higher risk of fragmented care.
• Standalone Services
  • Pros: Direct access to services; Cons: Potential lack of coordination leading to inconsistent care quality.

Patient Experience

During the Procedure:

• Regular interactions with the case manager.
• Regular communications regarding healthcare plan updates.

After the Procedure:

• Continuous support and progress monitoring.
• Improved sense of control and understanding of their healthcare plan.

Pain Management/Comfort:

• Not applicable as this is a non-invasive management service.