{"title":"Preparing for New Primary Care Models: The Role of Professional Case Management.","authors":"","doi":"10.1097/NCM.0000000000000825","DOIUrl":"10.1097/NCM.0000000000000825","url":null,"abstract":"","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 5","pages":"E13"},"PeriodicalIF":0.9,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660622","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Roles, Training, and Qualifications of Case Managers at Community Integrated Service Centers in Taiwan: A Narrative Review.","authors":"Ya-Wen Kuo, Wen-Li Hou, Jiann-Der Lee, Ching-Min Chen","doi":"10.1097/NCM.0000000000000791","DOIUrl":"10.1097/NCM.0000000000000791","url":null,"abstract":"<p><strong>Purpose of study: </strong>This study explored the roles, training, and qualifications of case managers in level A of Taiwan's long-term care (LTC) system, established within the Ten-Year LTC Plan 2.0, to identify their challenges and provide recommendations for enhancing their performance.</p><p><strong>Primary practice setting: </strong>This study focuses on community integrated service centers in Taiwan, which serve as key hubs for delivering LTC services to Taiwan's aging population.</p><p><strong>Methodology and sample: </strong>A narrative review approach was implemented, with an extensive analysis of the literature in terms of the functions and training requirements of and the professional challenges faced by case managers in the LTC sector. This review included articles published between 2016 and 2024 in both English and Chinese.</p><p><strong>Results: </strong>Case managers play a key role in linking LTC resources and coordinating care for older clients. However, they often face major challenges, including a high caseload, inadequate training opportunities, and a desire to quit, which adversely affect service quality and outcomes.</p>","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":" ","pages":"207-217"},"PeriodicalIF":0.8,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143442374","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Roles, Training, and Qualifications of Case Managers at Community Integrated Service Centers in Taiwan.","authors":"","doi":"10.1097/NCM.0000000000000824","DOIUrl":"10.1097/NCM.0000000000000824","url":null,"abstract":"","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 5","pages":"E14"},"PeriodicalIF":0.9,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660623","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Law and Ethics: A Complex Relationship.","authors":"Lynn S Muller","doi":"10.1097/NCM.0000000000000820","DOIUrl":"10.1097/NCM.0000000000000820","url":null,"abstract":"","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 5","pages":"227-228"},"PeriodicalIF":0.9,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660621","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Heaven Provo, Lisa Simmons-Fields, Ellen Fink-Samnick
{"title":"Interprofessional Partnership as a Pillar of Value-Based Care Delivery: Commentary on \"Preparing for New Primary Care Models: The Role of Professional Case Management\".","authors":"Heaven Provo, Lisa Simmons-Fields, Ellen Fink-Samnick","doi":"10.1097/NCM.0000000000000814","DOIUrl":"10.1097/NCM.0000000000000814","url":null,"abstract":"<p><p>Professional case managers (PCMs) play pivotal roles in the evolution of primary care as highlighted by the paper \"Preparing for New Primary Care Models: The Role of Professional Case Management.\" PCMs are influential in value-based primary care and are important members of interprofessional teams striving to achieve key care outcomes such as those emphasized in the Making Care Primary Model.</p>","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":" ","pages":"190-193"},"PeriodicalIF":0.8,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144041505","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Self-Advocacy and Access: Goals for Case Managers and Disability Managers.","authors":"Patricia Patty Nunez","doi":"10.1097/NCM.0000000000000821","DOIUrl":"10.1097/NCM.0000000000000821","url":null,"abstract":"","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 5","pages":"224-226"},"PeriodicalIF":0.9,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660624","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Is Case Management's Interprofessional Power Also Its Kryptonite?","authors":"Ellen Fink-Samnick","doi":"10.1097/NCM.0000000000000811","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000811","url":null,"abstract":"<p><p>Case management's interdisciplinary workforce is among the profession's superpowers. Use of the interprofessional team is intrinsic to workforce success, especially in demonstrating positive clinical, fiscal, and operational outcomes. However ongoing challenges within the industry contribute to case management's superpower being often viewed as its kryptonite. Amid the solid foundation imposed by standards of practice, research, and interprofessional education to validate the importance of interprofessional collaboration, what must happen for case managers across disciplines to stand together rather than siloed and apart?</p>","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 5","pages":"187-189"},"PeriodicalIF":0.8,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144660620","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Improving Health Care Proxy Documentation for Patients With Cognitive Impairment in an Acute Care Setting: A Quality Improvement Project.","authors":"Fiona S Koshy, Patricia A MacCulloch","doi":"10.1097/NCM.0000000000000826","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000826","url":null,"abstract":"<p><strong>Purpose: </strong>Advanced care planning supports discussions about patients' preferences for end-of-life care, frequently resulting in the completion of health care proxy documentation (HCP). This quality improvement project aimed to increase HCP documentation rates for hospitalized patients with cognitive impairment, including those diagnosed with dementia and delirium.</p><p><strong>Primary practice setting: </strong>This project was implemented at a 216-bed acute care, community-based teaching hospital in the northeastern United States.</p><p><strong>Methodology and sample: </strong>The intervention targeted case managers and nursing staff in medical-surgical and stepdown units. Case managers completed an asynchronous educational module on revised workflows for identifying and documenting health care proxy among cognitively impaired patients, followed by a post-training assessment. Concurrently, nursing staff received a practice alert reinforcing their role in verifying patient-designated health care agent upon admission. Program evaluation included demographic data, staff feedback, and aggregate chart reviews to measure changes in documentation rates and process adherence.</p><p><strong>Results: </strong>HCP documentation for hospitalized patients with cognitive impairment increased from an average of 62% to an average of 75.44% over the 12-week implementation period.</p><p><strong>Implications for case management practice: </strong>A structured, case manager-led workflow significantly improved the documentation of health care proxies for patients with cognitive impairment. Future initiatives should integrate nurse-led education on HCP verification and promote interdisciplinary collaboration to enhance advance care planning practices across care teams.</p>","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":" ","pages":""},"PeriodicalIF":0.9,"publicationDate":"2025-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144800497","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Marta Pruitt, Abby Matusik, Neelam Patel, Kathryn Kreider
{"title":"Utilizing a Nurse Discharge Navigator to Reduce Readmissions for Hospitalized Patients With Sepsis: A Quality Improvement Feasibility Study.","authors":"Marta Pruitt, Abby Matusik, Neelam Patel, Kathryn Kreider","doi":"10.1097/NCM.0000000000000823","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000823","url":null,"abstract":"<p><strong>Purpose/objectives: </strong>The purpose of this project was to evaluate the impact of a nurse discharge navigator implementing an education and structured outpatient follow-up program on reducing 30-day readmissions for adult patients with sepsis.</p><p><strong>Primary practice setting: </strong>This project was implemented at an 847-bed academic hospital in the southeastern United States.</p><p><strong>Findings/conclusions: </strong>Patient capture in the study was poor, driven by high rates of cancer diagnoses, comfort-directed care, and frequent discharges to postacute care. Readmission rates for patients receiving the full intervention (n = 16) were 25% (n = 4). Overall readmission rates for patients with sepsis in 2024 were 13.3% (n = 61). The outcomes of this project were influenced by the advanced comorbidities of the participants.</p><p><strong>Implications for case management practice: </strong>Case management of patients with sepsis should be comprehensive. Caregivers should be involved early to initiate education on the disease process, have clear communication with the follow-up team, and involve close, structured follow-up that can be adapted to the postacute care setting. One promising area for improvement of this intervention would be the inclusion of a Hospital at Home program as a transition program to the transition clinic.</p>","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":" ","pages":""},"PeriodicalIF":0.8,"publicationDate":"2025-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144691905","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Contracts Revisited.","authors":"Lynn S Muller","doi":"10.1097/NCM.0000000000000808","DOIUrl":"https://doi.org/10.1097/NCM.0000000000000808","url":null,"abstract":"","PeriodicalId":45015,"journal":{"name":"Professional Case Management","volume":"30 4","pages":"177-180"},"PeriodicalIF":0.8,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144188217","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}