Practicing Holistic Nursing as Intensive Case Management

Submitted by Joan M. Fenske RN, MS, PhD

Tags: advanced practice aging behavior Case Study emergency room Health Promotion holistic nursing methods mental health Mental Illness professional rn Psychiatry requirements treatment

Practicing Holistic Nursing as Intensive Case Management

Share Article:


Overview

This material illustrates Holistic Nursing modalities as practiced with individuals who are mentally ill. Holistic Nursing attends to the individual as an integrated person, caring for their mind, body and spirit. Modalities practiced elicit an individual’s intrinsic healing potential. Holistic Nursing defines health as a state of inter-relatedness of one’s values to the expression of such values. In the absence of such inter-relatedness, comes suffering. Multiple healing modalities are performed.

Frisch, Dossey, Guzzetta, Quinn (2000) identify multiple modalities currently practiced including a) finding meaning outside oneself (spiritual guidance), b) establishing a trust relationship (cognitive therapy), c) modeling appropriate behavior (behavior modification), d) daily diary entries (journaling), e) maintaining exercise regime (exercise and movement), f) planning meals (weight management), g) establishing relaxation skills (meditation) and h) encounter-based problem solving (rehearsed diplomacies) These modalities are essential when caring for patients with mental health concerns.

The following first-person case study examines case management evolving into Intensive Case Management (ICM) as an example of a healing modality and a holistic professional nursing practice. 1

The case study is presented using a narrative format. It chronicles a patient’s struggle to function coherently. Storytelling is a descriptive way to communicate the factual basis of challenging truths. Health professionals use narratives, retrospectively, to depict case studies (Woodside, 2010). Narratives link historical events to create a holistic interpretation of results.

This material establishes Intensive Case Management (ICM) as:

  • A Holistic Nursing modality,
  • A Holistic Nursing modality practiced within settings where professional Intensive Case Management (ICM) professional nursing services are delivered,
  • A Holistic Nursing modality that may be practiced independently under the aegis of an Intensive Case Management (ICM) professional nurse case manager. 2, 3

Also within the material, methods are delineated whereby appropriately licensed, accredited, certified and educated, described in the literature as Advanced Practice Nurses (De Nisco, S., Barker, A.M., 2013), may practice Intensive Case Management (ICM), independently, as a professional Nurse Contractor outside the employer-employee relationship.

Table 1 compares and contrasts differing nurse practice designations.

Table 2 compares and contrasts Holistic Nursing with Intensive Case Management (ICM) as professional nursing services are practiced within the case study presented.

Case Study Narrative

Snapping my phone shut, I turned it over in my hand unwilling to put it away. What had gone wrong? I’d dropped off Aimée, my current challenge, just the hour before. She seemed calm and collected, eager to bake brownies for tonight’s dessert. Now, a phone call informed me of her suicide attempt. Sitting in the backyard, using a kitchen knife, Aimée had cut her wrists, drawing blood.

Emergency Preparedness

Holistic Nursing Standard of Practice: Therapeutic Environment 4.2.3 specifies, “Holistic nurses integrate holistic principles, standards, policies and procedures in relation to environmental safety and emergency preparedness” (AHNA, 2000, p. 98).

“She’s more than I can handle.” Walter lamented.  “I can’t sleep”.

Walter’s a friend of Aimée’s mother; housing Aimée during her Out-patient regimen of Electroconvulsive Therapy (ECT). 4

“I’m driving her back to the psych unit”, he said.

A professional case management assessment of Aimée’s behavior signified her intent to commit suicide. Under the aegis of Holistic Nursing’s standard of practice, “emergency preparedness”, she needed admission to facility that would guarantee her “environmental safety”.

Her documented history of clinical depression reinforced the need to take immediate action.

Patient Assessment

Holistic Nursing Standard of Practice: Holistic Caring Process 5.1.1: specifies, “Holistic nurses use an assessment process including appropriate and holistic methods to systematically gather information” (AHNA, 2000, p.122).

Case Study

This is what is known about Aimée. Her psychiatrist communicated the     following:

  • Diagnoses: DSM-IV Bipolar II Disorder: Code 296.89,       
  • Diagnoses: Major Depression Disorder: Code 296.32,                     
  • Diagnoses: with an additional component of Bipolar II Disorder entitled Atypical Features including weight gain, hypersomnia (excessive sleepiness), and sensitivity to rejection.5

Yet that’s not the whole story; under intensive case management the past two years, Aimée also incorporated the following symptoms into her diagnoses:

  • Hypomania (disproportionate excitement); exhibiting episodes of anorexia, intensive talking, excessive socialization and out of control spending, and,
  • Refusing bipolar-specific prescriptions, due to exceptional weight gain, she was often un-medicated.

In addition, she was a:                                                                                    

  • Discharged patient from multiple medical emergency rooms and psychiatric in-patient hospitalizations,
  • Survivor of various suicide attempts,
  • Patient at risk for addiction, abusing alcohol and drugs,
  • Recent graduate of a 28-day licensed, certified, court ordered residential treatment center for individuals recovering from alcoholism and drug addiction.

Knowing Aimée

Holistic Nursing Standard of Practice: Holistic Caring Process 5.1.2 “Holistic nurses value all types of knowing including intuition when gathering data from a person when appropriate” (AHNA, 2000, p.122).

Aimée is not her illness. Her illness does not define her.

No matter how much of her personhood her illness claims, she is attractive, charming, creative and fun to be with. She  graduated, cum laude, from a local community college with     two Associate of Arts degrees. She is 44 years old.

Functionally, she’s is unemployed, unemployable and  homeless, and “just that far “ from prostituting herself    for drugs or drink.

Aimée’s ill, struggling, wanting her life back. 

Could I, as a Registered Nurse Contractor, practicing independently, apply holistic nursing modalities and Intensive Case Management (ICM) interventions others had not? 6 What unique professional nursing services would make a difference?

Who’d pay?

Balancing Economic Justice with Compassion

Holistic Nursing Standard of Practice: Implementation 5.5.5 specifies, “Holistic Nurses

provide care that is clear about and respectful of the economic parameters of practice, balancing justice with compassion” (AHNA, 2000, p.155).

It is possible to privately negotiate a fair, mutually agreed upon contractual agreement to pay for professional nursing services including Intensive Case Management (ICM) strategies incorporating holistic nursing interventions.

Yet, why not itemize phone numbers of the appropriate agencies; programs and intake workers then encourage family and friends to assist her? Would Aimée follow their counsel, make and keep necessary appointments, obtain essential services then comply with arrangements made for her? If such arrangements were made uniquely for her, in her best interest, would this work?

The answer is no.

Exhausted former husbands, sisters, and long term family friends initiated such strategies again and again. All attempted to keep her medicated, housed, solvent, fed and out of jail. She’d been arrested twice, finally admitted and hospitalized via the emergency room for

an overdose of Tylenol ®.

 

Establishing a Positive Sense of Self

Holistic Nursing Standard of Practice: Holistic Nurse Self-Care 3.1.4 specifies, “Holistic Nurses consciously cultivate awareness and understanding about the deeper meaning, purpose, inner strengths, and connections with self, others, nature, and God/Life Force/Absolute/Transcendent” (AHNA, 2000, p. 64).

Sustaining a relationship with an individual with mental illness is burdensome. No individual, alone, has the emotional capacity to relate to the angst manifested by someone tormented with anxieties. The patient is unable to self regulate thus one’s own individual professional nursing responsibility to care for such an unstable individual for a 24 hour, 7 day a week shift, is untenable. Responsibility must be shared, either within an institutional setting or adhering to an organized structured day program.

The narrative continues:

Scrounging money from an ex-husband, Aimée lived alone for years, getting through the day with her two cats and a dog to keep her going. When her stepsister moved her out of state: all pretenses Aimée could live alone evaporated. Acting out another suicide attempt landed her back amidst her providers seeking Electroconvulsive Therapy (ECT) since her prescribed Clonazepam™ (Klonopin™) dosage, already excessive, could no longer be increased. All other possible medication regimes had been exhausted. A last-ditch effort by an old-time family friend provided Aimée with temporary housing during the course of her latest round of therapies.

Promoting Patient Problem Solving

Holistic Nursing Standard of Practice: Implementation 5.5.2 specifies, “Holistic Nurses support and promote the person’s capacity for the highest level of participation and problem-solving in the plan of care and collaborate with other health team members when appropriate” (AHNA, 2000, p.155).

Many times we listen to our friends and families bemoaning their kindred’s tragic life trajectories. It is more than any one individual can handle alone. Are there alternatives?  Life skills, habilitation and activities of daily living are compromised when individuals age, are developmentally disabled, mentally ill or have been institutionalized for considerable lengths of time. Our society is complex, cherishing self-sufficiency and self-reliance. Not all individuals have the capability to achieve self-mastery thus attaining our cultures’ multifarious standards. De-institutionalizing or delivering those at-risk to board and care homes has been tried and failed. With resources scarce, public programs eliminated and community programs minimally staffed, a variety of options are now considered.

The concept of Intensive Case Management (ICM) emerged as an option. In the literature, reviews of models and functions of ICM include models sharing four attributes:

  • “Low client/staff ration,
  • In-vivo site for treatment,
  • Frequent and intense contact to forge regular and strong ties with clients,
  • Open ended lengths of service” (Schaedle, 1999 p. 34).

The purpose of Intensive Case Management (ICM) is to prevent diagnosed mentally ill patients to sustain themselves in the community. This means the patient cooperates with the ICM professional nurse case manager as medical and psychiatric services are arranged. The patient participates and follows through by keeping appointments and taking prescribed medications. Patients require multiple services since their mental illness renders them disabled, unable to function. Those who are mentally ill are unable to remain employed thus end up homeless. Services required include job seeking and training, appropriate housing, transportation, childcare and access to food and clothing. When the family recognizes their inability to assist their mentally ill family member in any way, they seek understanding. Educating the family about mental health and symptoms of the mentally ill, the case manager assures the family’s continued involvement.  The family functions for the patient as an essential support group. Chronic mentally ill patients lose their family’s involvement as their symptoms progress. The case manager continually assesses the patient determining the multiple factors inhibiting their ability to initiate activities and achieve desired recovery. For example, attending regular Alcoholics Anonymous (AA) meetings assists recovery if a patient’s symptom, addiction, prevents recovery. Patients have personal goals related to vocation options and their life’s projectory. Eliciting patient goals and personal expectations requires skilled case management by the ICM professional nurse case manager.

Programs and agencies define Intensive Case Management (ICM) professional services in ways to meet their own objectives:

“Intensive case management is responsive to consumers’ multiple and changing    needs, and plays a pivotal role in coordinating required services from across the          mental health system as well as other service systems (i.e., criminal justice, developmental services, addictions). Case managers fulfill a vital function for consumers by working with them to realize personal recovery goals. Case       managers work to build a trusting and productive relationship with the consumer and to provide the support and resources that the consumer needs to achieve goals, stabilize his/her life and improve his/her quality of life”. 6

When initiating Intensive Case Management (ICM), the professional nurse case manager strives to develop an ongoing relationship with the patient. Collaborating with the patient, respectful of their current dysfunctional struggles, yet aware of the patient’s potential for self-healing, a therapeutic plan is created.

Holistic Nursing Modalities Prioritized as Intensive Case Management Strategies

Holistic Nursing Core Value: Implementation 5.5 specifies, “ Each person’s plan of holistic care is prioritized and holistic nursing interventions are implemented accordingly” (AHNA, 2000, p.154).

Unique Healing Plan

Each program, enrolling the patient (referred to as “consumer” or “client”), specifies how Intensive Case Management (ICM) professional nursing services will be delivered. The program sets up a negotiated dynamic since ICM professional nursing services, to be successful, functions to provide access to services meeting each patient’s singular needs. Interaction between the patient and the ICM professional nurse is an ongoing and evolving process. Often, the patient confidentially confides their privations to their ICM professional nurse case manager. To be effective, the ICM professional nurse models behavior useful for the patient’s future behavior. Within their ICM professional nursing relationship, patient difficulties are assessed, needed services are identified, and appointments with appropriate program intake workers are made. The ICM professional nurse takes personal responsibility for driving the patient to the appointment, waiting in crowded rooms for the appointment number to be called, attending each appointment interview to clarify intake worker queries plus modeling appropriate behaviors and attitudes necessary to solicit benefits and referral services.

The dynamics of holistic nursing, and the modalities practiced, meld meticulously with those of Intensive Case Management (ICM) provided by the professional nurse.

The reciprocal relationship between the patient and the ICM professional nurse relies upon the patient’s belief, expectation, conviction and confidence that interventions initiated by the ICM professional nurse will lead to predetermined positive outcomes. Trust is established.

Holistic Nursing Standard of Practice: Implementation 5.5.4 specifies, “ Holistic nurses advocate that the person’s plan, choices, and unique healing journey be honored” (AHNA, 2000, p. 155).

Further delineating the professional nurse’s interaction with the patient is necessary to clarify the scope of skills used to coach each patient and “nudge them” along the therapeutic path. Within the trust relationship, the professional engages the patient according to patient’s behavioral or clinical behavior. The professional’s skill set provides ongoing patient assessment to determine the quality of needed therapeutic exchanges. Questioning the patient’s perception of reality is often required. The professional interaction is fluid, blending therapeutic exchanges with coaching strategies yet never verging on manipulative or fraudulent scheming.

Intensive Case Management (ICM) is further defined as the development of essential caring relationship between a professionally licensed nursing case manager and the patient. A trusting and dynamic relationship, when established, yields the patient’s hidden incongruities. As assessed needs become apparent, the ICM professional nurse case manager intervenes, using appropriate holistic nursing modalities on the patient’s behalf, in a supportive and protective manner across a variety of service systems. Holistic nursing modalities as well as ICM professional nursing interventions facilitates the patient’s ability to utilize and gain access to comprehensive and coordinated services comprising of crisis intervention, psychiatric and health care services including:

  • Public Assistance, Food Stamp eligibility,
  • Medical Care, Alcohol and Drug Treatment,
  • Family Education and Support, Counseling,
  • Education and Job Training,
  • Housing and Transportation.

Early intervention in crisis situations diverts the patient from unnecessary, traumatic, in-patient hospitalization. Cases followed by Intensive Case Management (ICM) professional nurse case managers are usually limited to case loads of ten individuals. The with expected length of time assigned to intensively case manage a consumer or client is two years.

At first reading, Intensive Case Management (ICM) professional nursing services seem similar to case management activities historically provided by public health nurses and licensed social workers. Yet ICM professional nursing services differ significantly. Familiar case management activities segue into the ICM professional nursing services model when a patient’s needed interventions are crucial for sustaining their functional autonomy. This means the patient is at imminent risk of being legally incarcerated in jail or prison, consigned to a developmental disability institution or mental health facility before becoming homeless.7 Not only does the ICM professional nurse aim to prevent psychiatric in-patient incidents and/or re-hospitalization, an explicit goal of ICM is to prevent homelessness.

Federal, state, county and local private agencies use the Intensive Case Management (ICM) Program model. These include:

Federal:

The Veteran’s Administration (VA) uses ICM professional nursing  services in approved VA medical centers for veterans meeting the following criteria: a) “Diagnosis of Severe and Persistent Mental Illness, b) Severe Functional Impairment (not capable of stable self-maintenance in a community living situation), c) Inadequately Served (by conventional clinic-based out-patient services), and d) High hospital use (over 30 days            of annual psychiatric hospitalization or 3 or more episodes of psychiatric hospitalization)”. 7

State:

State governmental agencies draw from a variety of models that incorporate strategies of Intensive Case Management (ICM) services.8, 9  State governmental Departments of Aging, Health Services, Mental Health and Corrections use Intensive Case Management (ICM) professional nursing services in the following manner:

  • Oklahoma and Missouri monitor those with schizophrenia and other diagnosed cases of mental illness to assure a patient successfully functions in the community, remains employed and sustains appropriate medical interventions. 10
  • California uses unique State classifications and duty statements to employ Registered Nurses as intensive case managers to monitor Medicaid recipients’ inappropriate or over utilization of benefits. 11
  • Oregon contracts with RN’s to case management patients’ multiple mental health hospitalizations, homeless seniors, newly released prisoners with addiction issues and provide in-home support for psychotic children. 12

County:

County social service programs provide intensive case management services to alleviate and support families’ in      imminent danger of         losing employment, being evicted from housing, at-risk for                                            becoming destitute and losing custody of their children due to child              neglect and/or abuse.

Local private agencies:

Catholic Charities. identify, assess and intensively case manage clients referred to them: a) during a local hospitals’ discharge planning process, b) from the police departments for crisis intervention for abused mothers, and c) from school health programs of homeless school age children in need of shelter.13

Holistic Standards of Caring and Healing

Holistic Nursing Core Value 2: Holistic Ethics; specifies under Standard of Practice 2.1;   “ Holistic nurses hold to a professional ethic of caring and healing that seeks to preserve wholeness and dignity of self, students, colleagues, and the person who is receiving care in all practice settings, be it in health promotion, birthing centers, acute or chronic care facilities, end-of-life centers, or homes” (AHNA, 2000, p. 23).

Components of Intensive Case Management (ICM) provided by a professional nursing case manager are constantly updated.  As needed services are identified and holistic nursing modalities are initiated, services are documented, delivered and tracked.  Academia assesses and evaluates innovative interventions to determine whether newer strategies better achieve ICM’s primary purpose; i.e., aiding the patient to sustain participation as a constructive member of the community.14 In this manner, innovative components of skilled ICM professional nursing case managers’ activities become established as “best practices”, the emphasis being upon patient stabilization.

Families with a relative such as Aimée have a difficult time accessing services on their own behalf. Only when an individual becomes known to the system, either by emergency room admission with mandated discharged planning or arrested then jailed and appearing in judicial settings, do Intensive Case Management (ICM) professional nursing services become available, upon referral, for the patient and their families. 15

All the above options assume the Intensive Case Management (ICM) professional nurse is an employee functioning under the authority established by federal and state law and licensing regulations plus abiding by the local organization or agencies’ program’s professional protocols.

May a licensed, accredited, credentialed and educated Nurse Consultant, building an Intensive Case Management (ICM) professional nursing services practice, function as a Registered Nurse Contractor and establish one’s self independently?

Establishing Competency in Diverse Community Settings

Holistic Nursing Standard of Practice: Holistic Philosophy and Education 1.1.2 specifies, “Holistic nurses support, share, and recognize expertise and competency in holistic nursing practice that is used in many diverse clinical and community setting” (AHNA, 2000, p.4).

A Nurse Consultant, uniquely termed a “Registered Nurse Contractor”, if properly licensed, accredited, credentialed and educated may practice independently, meaning their contractual scope of work functions outside of a typical employer-employee relationship. 16

To function independently, outside an employer-employee relationship, requires negotiating a private contract detailing the professional nursing services to be delivered.

The contract format used should be vetted by a lawyer knowledgeable about the definition of professional services.17 Professional services are services delivered by individuals who have completed extensive academic education and training. Often, the individual claiming a professional background is licensed and practices under State legal jurisdiction. Professional services delivered incorporate assessment and evaluation derived from professionally accepted standardized criteria providing essential data interpreted, used to prescribe a plan or course of action. It is the professional recommendations that form the elements of the contract and are negotiated with the “contractee”.18, 19 Contracts may be negotiated with private individuals, their legal representative or government programs or institutions. Professional service contracts may be negotiated with private parties, and private businesses such nursing homes and facilities. Local, state and federal government agencies also contract with individuals for professional services. 20   As stated by Bemis (In certain states, an RN can contract with the state Medicaid system and become an RN provider. Services are provided to Medicaid patients, and the program picks up the fee for the nursing care.”

Integrating Holistic Practice within State Laws and Regulations

Holistic Nursing Standard of Practice 2.1.2 specifies “Holistic nurses integrate the standards of holistic practice with applicable state laws and regulations governing nursing practice”(AHNA, 2000, p. 27).

Individual states govern nursing practice under explicit State law. State law also regulates contracts. Providing Intensive Case Management (ICM) professional services outside an employer-employee relationship may be provided within the context of a formal work-for-hire or “Professional Services” contract.21 It is possible for credentialed Nurse Consultants, as Registered Nurse Contractors, to negotiate contracts, provide services and be reimbursed according to terms stipulated within the contract.  They are professionally and legally accountable for the completing the terms of a signed and dated contract.

It is possible to deliver holistic nursing modalities, incorporated within Intensive Case Management (ICM) professional nursing This means completing a Holistic Nursing Certification Program and sustaining timely Holistic Nursing continuing education units.

Transformational Leadership

Holistic Nursing Standard of Practice 2.2.1 specifies: “Holistic nurses strive to use nursing theories to develop holistic nursing practice and transformational leadership”  (AHNA, 2000, p. 27).

This entails setting up, as a Nurse Consultant, an Intensive Case Management (ICM) professional nursing practice as an independent professional nursing practitioner, uniquely educated and specifically termed, “Registered Nurse Contractor”.

This requires:

  • Organizing and preparing a business plan,
  • Defining one’s professional practice,
  • Detailing one’s professional services,
  • Developing a legal contract,
  • Obtaining mal-practice insurance,
  • Joining professional organizations,
  • Arranging professional consultation,
  • Obtaining professional oversight and medical back-up,
  • Creating “on-call” coverage from other professionally licensed case managers,
  • Actively engaging in appropriate Holistic Nursing Certification and Registered Nurse continuing education and licensing requirements.

Part of one’s business plan is designating lawyers and physicians for consultation and review. Promoting relationships with appropriate public and private organizations is achieved by establishing inter-program agreements to define and provide professional linkages.

A basic service contract always includes names of the parties to the contract, services to be performed, dates services will be provided, assurances, guarantees and warrantees covering liabilities. The amount and terms of payment are included as well.

Details of specified enhanced nursing services, including holistic nursing modalities, and Intensive Case Management (ICM) professional nursing services, may be itemized in a “Professional Services” contract, with the contract’s addendum and scope of work termed “Intensive Case Management (ICM) professional nursing services”.

Contractual obligation assumes; a) compensation, b) liability insurance, c) time documentation, d) patient record keeping, and e) report filing. Adherence to federal, state and local laws and regulations must be observed. Within the scope of work, the relationship between the contractual parties is defined.

Practicing the Art and Science of Holistic Nursing

Holistic Nursing Standard of Practice: Core Value 1 Holistic Philosophy and Education specifies, “ Holistic Nurses develop and expand their conceptual framework and overall philosophy in the art and science of holistic nursing to model, practice, teach and conduct research in the most effective manner possible” (AHNA, 2000, p. 1).

The medical and health care community, informed of the methods used to build ones Intensive Case Management (ICM) professional nursing practice, should be educated to understand Holistic Nursing standards of practice. 22 This may be communicated by professional letter, visits to physicians’ and clinic offices as well by presentations given at local professional meetings. “Like any form of referral, word of mouth from a trusted source to another trusted source is the best” (pg.51, Schmoor, 2013).

Specific components of holistic nursing modalities as well ICM professional nursing services are detailed. Diagrams of referral networks and follow-up procedures are displayed to demonstrate how holistic nursing modalities as well as ICM professional nursing services fit into the community system of patient care and management. Appropriate interagency agreements facilitate patient care and clarify how case management is provided. Participating in organization meetings and professional seminars provide further understanding of the intent of professional referral and case management services.

It is important to acknowledge that under each States’ licensing act, a Registered Nurse is responsible for ascertaining their own competency in nursing services initiated and delivered. Under each state’s licensing act, each Registered Nurse is liable for knowledgeable, skilled, and proficient nursing service delivery. 23

When Registered Nurses provide Intensive Case Management (ICM) professional nursing services as independent Nurse Contractors’, they must consider:

  • State nursing law and regulations,
  • Legitimate sources of referral,
  • Legal status and competence of patient,
  • Legally designated trustee,
  • Patient or trustee approvals, signatures and dates,
  • Standardized contract language specifying the professional services rendered,
  • Confidentiality guarantees; including mandated Health Information Patient Protection Act (HIPPA) procedures, 24
  • Maintaining confidential patient files and record keeping,
  • Negotiating a mutually approved Intensive Case Management (ICM) plan,
  • Description of services provided,
  • Performance of evidence-based practices,
  • Listing holistic modalities engaged,
  • Evaluation methods determining positive or negative outcomes,
  • Guarantees, warrantees, liabilities and insurances,
  • Description of reimbursement strategies and mechanisms,
  • Description of billing and reporting process,
  • Period of time, dates, covered by contract,
  • Contract termination and renewal stipulations,
  • Professional medical and psychiatric oversight and review plus options for second opinions.

As the patient’s history file expands comprehensively; maintaining and compiling a detailed medical, psychiatric, health, education, employment, and family history becomes an Intensive Case Management (ICM) professional nursing obligation. The ICM professional nursing services case manager is responsible for:

  • Reviewing, interpreting and updating file content, as appropriate, with client and family,
  • Appraising physical, medical, psychiatric records,
  • Preparing and distributing patient status reports,
  • Assessing activities of daily living competencies and needs,
  • Developing, coordinating and prioritizing a professional therapeutic ICM plan including reasonable goals and measurable objectives plus the holistic nursing modalities used as interventions,
  • Initiating tracking and case management strategies,
  • Developing community-based referral resources,
  • Although instituting personalized, dependable 24/7 crises care management procedures and protocols; the ICM nursing professional must specify their reliance upon emergency personnel for patient intervention in crisis care situations.
  • Documenting, recording, distributing and reporting required information to appropriate agencies and programs,
  • Create, maintain and sustain a patient’s “Community of Care” network.
  • Institute an appropriate evaluations process to collect outcome data.

Establishing Social Networks and Environments

Holistic Nursing Standard of Practice: Therapeutic Environment 4.2.5 specifies, “Holistic Nurses promote social networks and social environments where healing can take place” (AHNA, 2000, p.105).

Community of Care

Creating, implementing, maintaining and sustaining a “Community of Care” as a patient’s major support group is essential for successful functioning of an "at-risk" patient within the community. Building a “Community of Care” dynamically establishes the substance of a patient’s holistic nursing care and Intensive Case Management (ICM) professional nursing service therapeutic plan.

Rationale for Independent Practice

Not satisfied with public or private case management services for their family member, families seek direct involvement. Frequent communications from licensed professionals regarding the status of their family member is sought. Families exhaust options, such as inducing the family member to live with them or assisting the family member sustain residency in a licensed board and care home. All options unravel. No option succeeds over time nor remains a good fit for the unique situation presented by the individual “at-risk” family member. This is especially true when the “at-risk” family member “acts out”.

As stated by Bemis (2008), “An increasing number of RNs are becoming “wellness coaches" as more insurance plans implement wellness programs for employees. Particularly popular with the Baby Boomers, this option extends beyond traditional corporate initiatives. Some patients are hiring their own wellness coaches to help them stay well and active.”.

Families are willing to privately negotiate Intensive Case Management (ICM) professional nursing services contracts to pay for ICM professional nursing services. As holistic nursing modalities are discussed, agreed to and incorporated within the patient’s ICM professional nursing plan, distressed family members voice their relief.

Holistic nursing modalities enhance Intensive Case Management (ICM) professional nursing services as families recognize the support provided by Advanced Practiced Nurses so educated and certified. Acknowledging their family member as an integrated whole person with the potential for self-healing gives families hope. Health promotion and health education provides families additional information regarding their family members’ illness and concerns.

Holistic Nursing Standard of Practice: Evaluation 5.6.1 specifies, “Holistic nurses collaborate with other health care team members when appropriate in evaluating holistic outcomes” (AHNA, 2000, p.168).

As demand increases for Intensive Case Management (ICM) professional nursing services, and academic evaluations document the stabilizing effect upon the at-risk patient population, the fact that at-risk patients, are successfully living in the community, not being re-institutionalized, options for “third-party reimbursement” e.g., Medicaid and Medicare, will follow.25 As stated by Bemis (2008), “In certain states, an RN can contract with the state Medicaid system and become an RN provider. Services are provided to Medicaid patients, and the program picks up the fee for the nursing care. The respite families obtain knowing the support their family member receives from ICM professional nursing services will promote such change.” (p. 47).

No longer waiting for family members to come to the attention of governmental organizations and agencies, families seek enhanced holistic nursing modalities uniquely incorporated within Intensive Case Management (ICM) professional nursing services for family members who are:

  • Mentally ill,
  • Developmentally Disabled,
  • Released from incarceration or prison,
  • Elderly and living alone.

What is unique about the above listed groups is that:

  • Their condition is chronic, long term, and unlikely to be resolved,
  • Their condition is associated with immediate and future unforeseen medical problems,
  • They are at risk for becoming lost to follow-up and/or homeless,
  • They are at risk of being arrested and/or institutionalized,
  • They are at risk of being deceived, swindled or victimized,
  • Their financial status is problematic with on-going issues,
  • Their existing case management services have failed.
  • Their institution, agency or program changed personnel, altered services and programs.

Stabilizing the Patient

Holistic Nursing Core Value: Evaluation 5.6 specifies, “Each person’s response to holistic care are regularly and systematically evaluated and the continuing holistic nature of the healing process is recognized and honored” (AHNA, 2000, p. 168).

Case Study Continued: Where is Aimée now?

Aimée’s Community of Care members were readily identified. Aimée’s mother was a single mother, dying of breast cancer, leaving Aimée bereaved, unattended and under age. Aimée had a stepmother, sister and brother.                         In addition, Aimée’s mother had many close friends who cared deeply about Aimée, wanting her care safely secured. Recovering from her Electroconvulsive Therapy,                         she stayed with her mother’s friend.                         Aimée’s Community of Care included Aimée’s stepsister,                         two of her mother’s friends, an ex-husband, Aimée herself,                         plus her Intensive Case Management (ICM) professional nursing services case manager. Priorities included within                         her ICM professional nursing services plan were:

  • Housing,
  • Finances including governmental benefits and food stamps,
  • Psychiatric and medical care,
  • Transportation,
  • Job training and education.

Monthly scheduled “phone bridges” allowed Aimée’s Community of Care participants to communicate on a specific date and at a specific time. In addition, all could ascertain from the group’s collective interaction with Aimée, listening to her conversation, whether or not she was successfully functioning. Aimée applied for a variety of governmental benefits, including Social Security Disability and Supplemental Security Income (SSI) requiring lengthy appointments and time-consuming interviews. The dreaded applications were completed playing a made-up life story question and answer game. Humor and patience were essential. The numerous psychiatrists and physicians Aimée had seen while obtaining psychiatric medications and interventions, plus her innumerable institutional admissions, documented her mental illness. Her disability was sufficiently verified and on-going monthly benefits were granted. Medicaid and Medicare benefits are granted as part of Social Security Disability benefits thus nearby psychiatric, mental health and medical clinics accepted Aimée and her Medicaid and Medicare payments. Issues related to transportation were solved, as Aimée owned an older car, with up to date insurance and license, thanks to oversight provided by her ex-husband. Her Community of Care assumed responsibility for monitoring potential parking and moving violations. To assure mandatory annual Social Security appointments were scheduled and kept, a member of her Community of Care accompanied her, providing her emotional support. Job training and education remained problematic given her inability to sustain commitment to her stated ambitions. Attempting to achieve her own wished-for training goals frustrated her. Since Social Security benefits are “needs tested”, working, even at minimum wage level, wasn’t an option. As an alternative, volunteer work in an animal shelter was incorporated into her Intensive Case Management (ICM) professional nursing services plan serving as a training option.

Conclusion

Responsibly for getting through each day, maintain daily schedule, care for her pets and plants, is now hers, alone. Aimée initiates conversations and activities with her friends, relatives and Community of Care participants. Her birthdays are remembered and celebrated by all.

That is as much life as Aimée can handle.

Aimee’s Community of Care participants will monitor her activities of daily living and remain in place if dysfunctional needs re-emerge.

If the Intensive Case Management (ICM) professional nursing services plan goal was to stabilize Aimee’s life, house and feed her, sustain her within the community without psychiatric incident, then the ICM professional nursing services plan goal was achieved.

The possibility for destabilizing incidents lurk. Eligibility for benefits change. Friends and family become ill. Beloved pets die.

The only constant is change.

References

Ackley, B. J., Ladwig, G.B. (2011). Nursing Diagnosis Handbook. St. Louis, MI   63043:             Mosby/Elsevier.

Bemis, P. A. (2011). Self-employed RN: how to become a self-employed RN and/or           business owner, (3rd Ed.). Rockledge, Fl 32156-1081: National Nurses in            Business Association, Inc. ©. 

            (http://www.nnba.net)

Burns, T., Catty, J., Dash, M., Roberts, C., Lockwood, A., & Marshall, M.  (2007).

            Use of intensive case management to reduce time in hospital in people with           severe mental illness: systematic review and meta-regression. The BMJ (formerly             the British Medical Journal), BMJ 2007; 335: 336.

Creasia, J.D., Triberg, E. E., (2011). Conceptual foundations: the bridge to            professional nursing practice, (5th Ed.). St Louis, MI 63043: Elsevier,      Mosby.           

            (http://www.elsevier.com)

De Nisco, S., Barker, A. M. (2013). Advanced practice nursing: evolving roles for            the transformation of the professional. Burlington, MA 01803: Jones & Bartlett           Learning. 

            (htttp://www.jblearning.com)

Dieterich, M., Irving, C.B., Park, B., & Marshall, M. (2010). Intensive case management    for severe mental illness. Cochrane Database of Systematic Reviews 2010,

            Issue 10. Art. No.: CD007906. © 2011 The Cochrane Collaboration.

            Hoboken, NJ 07030-5774: John Wiley & Sons, Ltd.

            DOI: 10.1002/14651858.CD007906.pub2.

 

Dziegielewski, S. (2013). The Changing Face of Health Care Social Work, (3rd Ed.).        Opportunities and Challenges for Professional Practices. New York, NY 10036:        Springer Publishing Co. LLC.           

            (http://www.springerpub.com)

Eliopoulos, C. (2013). Georontological Nursing, (8th Ed.). Philadelphia, PA 19103:           Wolters Kluwer Health, Lippincott Williams & Wilkins.

Frisch, N.C., Dossey, B.M., Guzzetta, C.E. & Quinn, J.A. (2000). American Holistic         Nursing Association (AHNA): Standards of Holistic Nursing Practice.     Gaithersburg, Maryland 20878: Aspen Publishers, Inc.,             

            (www.aspenpublishers.com).

Hall, J., Callaghan P. (2008) Developments in managing mentalhealth care: a review of

 

            the literature. Ment Health Nurs. 29 (12),1245-72.

            doi:10.1080/01612840802370533

Hangan C. (2006). Introduction of an intensive case management style of delivery for a

 

            new mental health service. Int J Ment Health Nurs. 15(3), 157-62.

Hamric, A. B., Hanson, C. M., Tracy, M. F. & O’Grady, E. T. (2014). Advanced Practice             Nursing, (5th Ed.). St. Louis, MI 63043: Elsevier/Saunders.

            (www.elsevier.com)

Herrick C.A., Bartlett R. (2004). Psychiatric nursing case management: past, present,

            and future. Ment Health Nurs. 25(6), 589-602.

Kramer, M. K. (1990). Holistic Nursing: Implications for Knowledge Development and

            And Utilization. In N. Chaska (Ed.), The Nursing Profession: Turning Points. St

            Louis, MO 63122: Mosby.

McEwen, M., Pulles, E. (2011). Theoretical Basis for Nursing, (3rd Ed.). Philadelphia,      PA 19106: Wolters Kluwer Health, Lippincott, Williams & Wilkins.     

Mechanic, D. (1999). Mental health and social policy: the emergence of managed care.

            Boston, MA 02116: Allyn & Bacon.

Meyer, P. S., Morrissey, J. P.  (2007). A comparison of assertive community

            treatment and intensive case management for patients in rural

            areas. Psychiatric Services 58(1), 121-127.

Nelson, G., Aubry, T., & Lafrance, A. (2007).  A review of the literature on the     effectiveness of housing and support, assertive community treatment, and      intensive case management interventions for persons with mental illness who      have been homeless. American Journal of Orthopsychiatry 77(3), 350-361.

Pender, N. J. (1987). Health Promotion in Nursing Practice. Norwalk, CT 06855:

            Appleton & Lange.

Pratt, C. W.,  Gill, K. J., Barrett, N. M., & Roberts, M.M. (2012). Psychiatric

 

            Rehabilitation, (3rd Ed.). San Diego, CA 92101:Academic Press (Elsevior

             Science).

 

Raiff, N.R., Shore, B.K. (1993). Advanced case management: New strategies for the         nineties. 2455 Newberry Park, CA 91320:Sage Publications, Inc.

Santos, A. B.,  Stein, L. J. (1998). Assertive Community Treatment of Persons With

 

             Severe Mental Illness (1st Ed.). New York, N Y 10110: W.W. Norton & Co.

Schaedle, Richard W. (December 1999). Critical ingredients of intensive case       management: judgments of researchers/administrators, program managers and             case managers. Dissertation.com; (1st Ed.).

Schoor, Richard A. (2013). Suddenly solo: 12 steps to achieving your own totally independent health care practice. San Bernardino, CA: Richard A.

            Schoor MD ©

 Speer, D.C. (1998). A descriptive evaluation of intensive case management for older        adults with severe and persistent mental illness: Broward County Elderly         Services, Ft. Lauderdale, Florida, Tampa, FL 33612: Dept. of Aging and Mental     Health, Louis de la Parte Florida Mental Health Institute, University of South   Florida.

Street, A. (1991). From image to action: reflection in nursing practice.

            Geelong, Victoria 3220, Australia: Deakin University Press.

Vermeersch, P. E. H. (1988), Nieswiadomy, R. M. (1987). Foundations of nursing            research. Res. Nurs. Health, 11:351. Norwalk, CT: Appleton and Lange,

            doi: 10.1002/nur.4770110510

Videbeck, S. (2014). Psychiatric-mental health nursing. Philadelphia, PA 19103:

            Wolters Kluwer Health, Lippincott Williams & Wilkins.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notes
  1.             “Case management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services
 to meet an individual’s health needs through communication and available resources to promote quality cost- effective outcomes.”

Case Management Society of American: 
Standards of Practice 
for Case Management, Revised 2010©, All rights reserved.                                                                                    Case Management Society of America 6301 Ranch Dr., 
Little Rock, Arkansas 72223

http://[email protected]
www.cmsa.org IX).

2.         “Intensive Case Management Services (ICM) are for Individuals who:

  • Require intensive ongoing support to live successfully in the community,                                         
  • Will not or have not successfully used other mental health services and programs,             
  • Repeatedly use emergency rooms or inpatient services for crisis resolution,                                    
  • Are seriously and emotionally disturbed children and youth.”

[Description of the Use of Intensive Case Management Services], (2009).

Retrieved from:

http://www.cortland-co.org/mhealth/ICM.htm).

     

3.        “Intensive Case Management Services (ICM) are for individuals who:

                 Require intensive ongoing support to live successfully in the community,

                 Will not or have not successfully used other mental health services and                                    programs,

                 Repeatedly use emergency rooms or inpatient services for crisis resolution.”

                      

 [When Intensive Case Management is Necessary]. (2009).

Retrieved from:

 http://www.cotland-co.org/mhealth/ICM.htm).

4.        “Electroconvulsive therapy (ECT) is a procedure in which a brief application of electric stimulus is used to produce a generalized seizure.  It is not known how or why ECT works or what the electrically stimulated seizure does to the brain.  In the U.S. during the 1940’s and 50’s, the treatment was administered mostly to people with severe mental illnesses.  During the last few decades, researchers have been attempting to identify the effectiveness of ECT, to learn how and why it works, to understand its risks and adverse side effects, and to determine the best treatment technique.  Today, ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals.  It is generally used in treating patients with severe depression, acute mania, and certain schizophrenic syndromes.  ECT is also used with some suicidal patients, who cannot wait for antidepressant medication to take effect”.

 [Description of Electroconvulsive Therapy]. (2014).                
Retrieved from:
 http://www.mentalhealthamerica.net/ect#).   

5.         Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, (DSM-IV-TR®), American Psychiatric Association (2000).

6.         Healey, Kerry M., “Case Management in the Criminal Justice System” (1999) U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. 

            

[Case Management of Newly Discharged Prisoners]. (n. d.).

Retrieved from:

http://www.ojp.usdoj.gov/nij).

                                   

7.         Department of Affairs, Veterans Health Administration (VA) VHA Directive 2006-004. VHA Mental Health Intensive Case Management (MHICM) “This Veterans Health Administration (VHA) Directive provides policy regarding VHA’s mental health intensive case        management (MHICM) program for seriously mentally ill veterans,

a part of the mental health continuum of care”.                                                                              

                       

 [Federal government use of Intensive Case Managers in the Veteran’s Administration]. (n. d.).

Retrieved from:

http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1375).

8.         “Clinical Case Management is defined as having 13 distinct activities including engagement of the patient, assessment, planning, linkage with resources, consultation with families, collaboration with psychiatrists, patient psycho-education and crisis intervention. This approach focuses on the patient and by working with the patient’s diagnosis, intervenes by establishing proven pathways for healing such as psycho-education and family understanding and support.”

Kanter J. (1989). “Clinical case management: definition, principles, components”,

Hosp Community Psychiatry. Apr; 40 (4): 361-8.

Retrieved from:

http://www.ncbi.nlm.nih.gov/pubmed/2714749).

9.         Assertive Community Treatment (ACT) is:

“Assertive Community Treatment (ACT) is a way of providing many types of service to people with very serious mental illnesses. ACT teams provide services directly to people in their community. People who get ACT services receive the round-the-clock staffing of a psychiatric unit, but within the comfort of their own home and community. ACT team members are trained in the areas of psychiatry, social work, nursing, substance abuse, and vocational rehabilitation so they have the skills they need to meet the many needs of the people they serve. The ACT team provides these services 24 hours a day, seven days a week, each day of the year.”

                       

[Definition of Assertive Case Management]. (2014).

Retrieved from:

 http://dmh.mo.gov/mentalillness/progs/act.htm).

10.       Behavioral Case Management is the case management process used by Oklahoma State and is defined as being “a process that includes planned linkage, advocacy and referral assistance provided in partnership with a consumer, family members, law enforcement personnel, community agencies and other supports as defined by the consumer. This collaboration of services are to provide a continuum of care for persons that utilize services inclusive of, but are not limited to mental health, substance abuse, prevention or other services to support the consumer in self sufficiency and community tenure. Case management actions may take place in the individual’s home, in the community, or in a facility.  An ODMHSAS Certified Behavioral Health Case Manager works with the consumer and their identified supports, in accordance with a treatment plan developed with and approved by the recipient and qualified staff to reach the consumer’s goals to remain successful in their recovery.”

           

 [Description of Behavioral Case Management]. (n. d.).

Retrieved from: http://www.ok.gov/odmhsas/Mental_Health_/Certifications,_Credentialing_and_Training/Behavioral_Health_Case_Management/.

11.       The State of California employs Nurse Evaluators within the State’s Medicaid/Medicare Programs to assess patient over utilization.  “Nurse Evaluators, Health Services, are professional Nurses, licensed by the State of California who work for the Department of Health Services or other State agencies. Nurse Evaluators, Health Services, perform onsite evaluations of services and quality assurance reviews of facilities, detect and develop cases where fraud or abuse is suspected, monitor service provider claims, and conduct site reviews and audits. Nurse Evaluators, Health Services; are responsible for determining quality of care being received by program beneficiaries in health facilities and identifying levels of care to meet each beneficiary’s health care needs; for monitoring medical services of providers; evaluating prior authorization requests for a variety of medical services; for training and supervising other staff in regulations and implementation of the Medi-Cal or other health care programs; for taking independent action within professional protocols and legal limits of the Medi-Cal or other health care program; and for assistance in analysis of the program” 

                       

[Description of State of California’s Use of R.N. Classifications for Case Management]. (n. d.).

Retrieved from:

http://www.calhr.ca.gov/state-hr- professionals/pages/8143.aspx).

12.       “Personal and Professional Services are services from an individual or firm with specialized skills, knowledge and resources not available within a department. Be aware that this excludes architectural or engineering consultant services - these types of services must utilize the construction contracting process.”

 [Description of State of Oregon’s Use of R.N.’s to Provide Intensive

 Case Management]. (n. d.).

Retrieved from:

           

http://pacs.oregonstate.edu/procurement/personal-and-professional).

                       

13.       Private organizations receiving public funding include Catholic Charities, Homeless Action Coalitions. Catholic Charities include among its activities the following focus upon those at risk: “Sonoma County is home to programs for seniors, people who are currently homeless or at risk of homelessness, the poor in rural areas, people with dementia, legal immigrants and refugees, and more.” 

 [Use of Intensive Case Management by Local Agencies], (n.d.),

 Retrieved from:

http://www.srcharities.org/services/index.html).

14.       Schaedle, Richard W., (December 1999) “Critical Ingredients of Intensive Case Management: Judgments of Researchers/Administrators, Program Managers and Case Managers”. Dissertation.com; 1st Edition. See p. 32. 

  

15.       Safer Foundation©  “For more than 40 years, Safer Foundation’s mission has focused on reducing recidivism by supporting, through a full spectrum of services, the efforts of people with criminal records to become employed, law-abiding members of the community.”  

                 [Safer Foundation’s description of case managing those with a criminal                             record]. (2014).

Retrieved from:

http://www.saferfoundation.org).

16.       A formal contractual process is essential to detail services delivered by a

professional RN.

[Written Contract Formats], (n. d.),

Retrieved from:

https://www.cnapro.com/pdf/MPLContractArticleandExampleContract_1-26-11.pdf ).

 

17.       “What is a Professional Service? To be considered as a professional service, procurement must meet certain criteria. Professional services are procured under a statutory exclusion, which establishes different methods of procurement. A contract, which is procured as a professional service, when in fact it is not a professional service, is subject to being voided.

A professional service is defined as a service that requires specialized knowledge and training (often through long and intensive academic preparation) or in-depth experience in a particular field or discipline.

Professional services are professional, technical, or consultant services predominantly intellectual in nature. They may include analysis, evaluation, predicting, planning, or recommendation and usually result in the production of a report or completion of a task.”

[Definition of a Professional Service], (n. d.),

Retrieved from:

http://doa.alaska.gov/das/Procurement/profsvcs.html)

                       

18.       “GSA’s Federal Acquisition Service (FAS) is developing a next generation contract vehicle for complex professional services. The vehicle will be designed to address agencies’ needs for professional service requirements that:

                        Span multiple professional service disciplines;

                        Contain significant IT components, but are not IT requirements in and                                                 of themselves;

                        Contain Ancillary Support components commonly referred to as                                               ODCs;

                        Require flexibility for all contract types at the task order level                                                   including cost reimbursement; and

                        Any one or combination of all of the above.

OASIS will be able to provide both commercial and non-commercial services. The core disciplines of the contract will include program management services, management consulting services, logistics services, engineering services, scientific services, and financial services. We will engage federal agencies and Industry in a collaborative process to identify the most advantageous structure for this contract and the best   practices to incorporate into its design. Our goal is to create a contract vehicle that provides a total solution to agencies’ requirements while maximizing opportunities for small businesses.”

[Federal Government’s Use of Professional Services Contracts]. (n. d.).

Retrieved from:

http://www.gsa.gov/ )

                                                                                                                                                            

19.       Hardy, C.L. (eHow Contributor)“How to Become an Independent Nurse            Contractor”

 “Independent nurse contractors partner with facilities like home health providers, hospitals, rehabilitation centers and doctor’s offices to provide       hourly nursing support. As an independent contractor, these nurses take on the responsibility and liability of entrepreneurship, which affords them, job flexibility and convenient scheduling as they select and negotiate the terms of their contract with each facility. While this career channel requires strong      business management acumen in addition to nursing licensing and expertise,           becoming an independent contractor can be a desirable nursing career for professionals seeking career autonomy.”

 [Description of how to become an Independent R.N. Contractor]. (2014).

 Retrieved from:

http://www.ehow.com/how_6235034_become-independent-nurse-contractor.html) .

20.       Bemis, P. A., “The outlook for nurses as independent contractors’’ (2008) Huntington Beach, CA  92646. National Nurses in Business Association, Inc. ©

“Some self-employed RNs provide nursing care to patients, directly or indirectly. These professionals are commonly referred to as “independent contractors” or as     “RN providers” in the insurance world. The nursing care an RN can provide is defined by each individual state nurse practice act”.

Retrieved from:

www.modernmedicine.com/.

http://www.nnba.net/.

21.       Example Contract

[Contract Format for Independent Nurse Contractors]. (n. d.).

Retrieved from:

https://www.cnapro.com/pdf/MPLContractArticleandExampleContract_1-26-11.pdf).

22.       Most states have added a position statement to their nurse practice acts referencing holistic nursing, a specialty recognized by the American Nursing Association. For more information regarding Holistic Nursing standards and practices, see:

 [American Holistic Nursing Association]. (n. d.).

Retrieved from:

http://www.ahna.org/)

                         

23.       “Medical care still needs an order from a physician, unless the clinician is a nurse practitioner in a state that does not require physician supervision.

Options for independent contractors:

An RN may contract with the patient or the patient’s representative directly to provide services in the client’s home or, less frequently, within an established healthcare setting. Historically known as “private duty” nursing, these services are not covered by most insurance carriers. Since many patients today are unable to personally pay for nursing care, this option is often reserved for individuals, like celebrities, who can afford the services of a registered nurse.

In certain states, an RN can contract with the state Medicaid system and become an RN provider. Services are provided to Medicaid patients, and the program picks up the fee for the nursing care. Some stores are offering office space to nurse practitioners in hopes of attracting healthcare consumers. An NP or holistic NP can open an office and treat patients either independently or under the supervision of a physician. As is the case with a physician’s office, the patient or an insurance company pays for the nursing care. Nurse practitioners who apply to become Medicare RN providers—and bill according to its codes—will have some of their services covered under the federal       program.

An RN who owns a supplemental staffing firm or home health agency also can perform direct patient care. But he or she must be hired as an employee before delivering services.

An increasing number of RNs are becoming “wellness coaches” as more insurance plans implement wellness programs for employees. Particularly popular with the Baby Boomers, this option extends beyond traditional corporate initiatives. Some patients are hiring their own wellness coaches to help them stay well and active.”

[Functions of an R.N. Contractor]. (n. d.).               

Retrieved from:

http://www.modernmedicine.com/modern-medicine/news/self-employed-nurses-and-patient-care#sthash.Ob2mC58d.dpuf).

24.       HIPPA refers to the Health Insurance Portability and Accountability Act of 1996 (HIPPA). “The HIPAA Privacy Rule provides federal protections for individually identifiable health information held by covered entities and their business associates and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of health information needed for patient care and other important purposes.”

[Federal Government’s Definition of the Health Insurance Portability and

Accountability Act (HIPPA)]. (2014).         

Retrieved from:

http://www.hhs.gov/ocr/privacy/.

25.        “The Medicaid Waiver for Assisted Living provides services and supports for eligible older persons and adults with physical disabilities who otherwise would require care in a nursing home. The goal of the program is to provide services that allow an individual to live as independently as possible in a homelike, residential setting. Support usually includes personal services and light medical or nursing care. The waiver also covers case management, which helps older persons, persons with disabilities and caregivers get connected with the services that they need. Case managers help in three ways:

  • assessing (or evaluating) a person’s situation and needs;
  • working with individuals and their families to develop care plans to map out what

kind of services an individual needs, how often they are needed, etc.; and

  • providing ongoing coordination to see that an individual’s care needs are being met.”                                                                                                                                                                                                                                                                                  
  •  

Mollica, R. L. (2009).

[State Medicaid Reimbursement Policies and Practices in Assisted Living, p. 43].

National Center for Assisted Living American Health Care Association

             

Notes
  1.             “Case management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services
 to meet an individual’s health needs through communication and available resources to promote quality cost- effective outcomes.”

Case Management Society of American: 
Standards of Practice 
for Case Management, Revised 2010©, All rights reserved.                                                                                    Case Management Society of America 6301 Ranch Dr., 
Little Rock, Arkansas 72223

(http://[email protected]
www.cmsa.org IX)

2.         “Intensive Case Management Services (ICM) are for Individuals who:

  • Require intensive ongoing support to live successfully in the community,                                        
  • Will not or have not successfully used other mental health services and programs,             
  • Repeatedly use emergency rooms or inpatient services for crisis resolution,                                    
  • Are seriously and emotionally disturbed children and youth.”

[Description of the Use of Intensive Case Management Services], (2009),

Retrieved from:

http://www.cortland-co.org/mhealth/ICM.htm

     

3.        “Intensive Case Management Services (ICM) are for individuals who:

                 Require intensive ongoing support to live successfully in the community,

                 Will not or have not successfully used other mental health services and                               

programs,

                 Repeatedly use emergency rooms or inpatient services for crisis resolution.”

                      

 [When Intensive Case Management is Necessary], June 2009,

Retrieved from:

 [http://www.cotland-co.org/mhealth/ICM.htm

4.        “Electroconvulsive therapy (ECT) is a procedure in which a brief application of electric stimulus is used to produce a generalized seizure.  It is not known how or why ECT works or what the electrically stimulated seizure does to the brain.  In the U.S. during the 1940’s and 50’s, the treatment was administered mostly to people with severe mental illnesses.  During the last few decades, researchers have been attempting to identify the effectiveness of ECT, to learn how and why it works, to understand its risks and adverse side effects, and to determine the best treatment technique.  Today, ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals.  It is generally used in treating patients with severe depression, acute mania, and certain schizophrenic syndromes.  ECT is also used with some suicidal patients, who cannot wait for antidepressant medication to take effect”.

 [Description of Electroconvulsive Therapy], (2014),                
Retrieved from:
 http://www.mentalhealthamerica.net/ect#.    

5.         Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, (DSM-IV-TR®), American Psychiatric Association (June 2000).

6.         What is Intensive Case Management?                                                                                    “When you have completed treatment, you may still have other needs which can make continued recovery difficult if they are not resolved.  Such needs can occur in any other following areas:

            Housing                                                                                      

            Other basic needs (food, clothing, etc.)                             

            Childcare                                                                       

            Employment Education and/or job training            

            Transportation                                                                  

            Substance abuse treatment                                                     

            Legal problems                                                                          

            Mental health                                                                      

            Physical health                                                                          

            Family and social concerns                                                         

            Life skills (budgeting, resume building, etc.)

If help is needed in any of these areas, the Administrative Case Manager can refer you to the Intensive Case Management program.

           The goals of Intensive Case Management Services are to:

                        Promote sustained psychiatric recovery,                              

                        Reduce barriers and obstacles to achieving recovery,            

                        Insure that services enhance members’ goals and are provided in a                                           supportive community environment,                                                                                          Insure that members have responsible, self-determined personal and                                  vocational goals,                                                

                        Assist members in understanding mental illness,                            

                        Help members develop coping skills to deal with illness related issues,                                                                                                    Assist members in recognizing and managing symptoms.

To that end, we are committed to helping our clients experience:

                        Increased community tenure by minimizing the number and length of                                     hospitalization                                                      

                        Increased independence and subjective quality of life by acquiring and                                    maintaining permanent housing, developing money                                                        management skills, ensuring medication compliance, and                                               reducing symptomology,                                             

                        Increased participation in meaningful activity by completed referrals                                      to the Office of Vocational Rehabilitation and assistance with                                         job placements,                                             

                        Increased number of days of abstinence by encouraging attendance at                                     AA meetings, assisting with drug/alcohol related legal issues,                                                    and self-report of abstinence,                   

                         Increase in meaningful social relationships,                

                        Understanding and participation in psychiatric rehabilitation and                                             recovery principles,                                                   

                        Satisfaction with treatment received,                                                 

                        In-home individualized therapy on a weekly basis to address                                                     difficult and traumatic treatment issues,                                                                   Appropriate discharge planning with the inclusion of the individual’s                                                 expectations.”

[Functions of the Intensive Case Management Process]. (n.d.),               

Retrieved from:                                                                                                                    

http://www.cpa.net/index.aspx?nid=2636

7.         Healey, Kerry M., “Case Management in the Criminal Justice System” (1999) U.S. Department of Justice, Office of Justice Programs, National Institute of Justice.              

[Case Management of Newly Discharged Prisoners]. (n.d.),

Retrieved from:

http://www.ojp.usdoj.gov/nij

                                   

8.         Department of Affairs, Veterans Health Administration (VA) VHA Directive 2006-004. VHA Mental Health Intensive Case Management (MHICM) “This Veterans Health Administration (VHA) Directive provides policy regarding VHA’s mental health intensive case        management (MHICM) program for seriously mentally ill veterans,

a part of the mental health continuum of care”.                                                                               

                       

 [Federal government use of Intensive Case Managers in the Veteran’s Administration], (n.d.),

Retrieved from:

http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1375                

9.         “Clinical Case Management is defined as having 13 distinct activities including engagement of the patient, assessment, planning, linkage with resources, consultation with families, collaboration with psychiatrists, patient psycho-education and crisis intervention. This approach focuses on the patient and by working with the patient’s diagnosis, intervenes by establishing proven pathways for healing such as psycho-education and family understanding and support.

Kanter J. (1989). “Clinical case management: definition, principles, components”,

Hosp Community Psychiatry. Apr; 40 (4): 361-8.,

Retrieved from:

http://www.ncbi.nlm.nih.gov/pubmed/2714749

                       

10.       Assertive Community Treatment (ACT) is:

“Assertive Community Treatment (ACT) is a way of providing many types of service to people with very serious mental illnesses. ACT teams provide services directly to people in their community. People who get ACT services receive the round-the-clock staffing of a psychiatric unit, but within the comfort of their own home and community. ACT team members are trained in the areas of psychiatry, social work, nursing, substance abuse, and vocational rehabilitation so they have the skills they need to meet the many needs of the people they serve. The ACT team provides these services 24 hours a day, seven days a week, each day of the year.”

                       

 [Definition of Assertive Case Management], (2014)

Retrieved from:

 http://dmh.mo.gov/mentalillness/progs/act.htm

11.       Behavioral Case Management is the case management process used by Oklahoma State and is defined as being “a process that includes planned linkage, advocacy and referral assistance provided in partnership with a consumer, family members, law enforcement personnel, community agencies and other supports as defined by the consumer. This collaboration of services are to provide a continuum of care for persons that utilize services inclusive of, but are not limited to mental health, substance abuse, prevention or other services to support the consumer in self sufficiency and community tenure. Case management actions may take place in the individual’s home, in the community, or in a facility.  An ODMHSAS Certified Behavioral Health Case Manager works with the consumer and their identified supports, in accordance with a treatment plan developed with and approved by the recipient and qualified staff to reach the consumer’s goals to remain successful in their recovery.”

           

 [Description of Behavioral Case Management], (n.d.),

Retrieved from: http://www.ok.gov/odmhsas/Mental_Health_/Certifications,_Credentialing_and_Training/Behavioral_Health_Case_Management/

12.       The State of California employs Nurse Evaluators within the State’s Medicaid/Medicare Programs to assess patient over utilization.  “Nurse Evaluators, Health Services, are professional Nurses, licensed by the State of California who work for the Department of Health Services or other State agencies. Nurse Evaluators, Health Services, perform onsite evaluations of services and quality assurance reviews of facilities, detect and develop cases where fraud or abuse is suspected, monitor service provider claims, and conduct site reviews and audits. Nurse Evaluators, Health Services; are responsible for determining quality of care being received by program beneficiaries in health facilities and identifying levels of care to meet each beneficiary’s health care needs; for monitoring medical services of providers; evaluating prior authorization requests for a variety of medical services; for training and supervising other staff in regulations and implementation of the Medi-Cal or other health care programs; for taking independent action within professional protocols and legal limits of the Medi-Cal or other health care program; and for assistance in analysis of the program” 

                       

[Description of State of California’s Use of R.N. Classifications for Case Management], (n.d.),

Retrieved from:

http://www.calhr.ca.gov/state-hr- professionals/pages/8143.aspx

                       

13.       “Personal and Professional Services are services from an individual or firm with specialized skills, knowledge and resources not available within a department. Be aware that this excludes architectural or engineering consultant services - these types of services must utilize the construction contracting process.”

 [Description of State of Oregon’s Use of R.N.’s to Provide Intensive

 Case Management], (n.d.),

Retrieved from:

           

http://pacs.oregonstate.edu/procurement/personal-and-professional

                       

14.       Private organizations receiving public funding include Catholic Charities, Homeless Action Coalitions. Catholic Charities include among its activities the following focus upon those at risk: “Sonoma County is home to programs for seniors, people who are currently homeless or at risk of homelessness, the poor in rural areas, people with dementia, legal immigrants and refugees, and more.” 

 [Use of Intensive Case Management by Local Agencies], (n.d.),

 Retrieved from:

http://www.srcharities.org/services/index.html

15.       Schaedle, Richard W., (December 1999) “Critical Ingredients of Intensive Case Management: Judgments of Researchers/Administrators, Program Managers and Case Managers”. Dissertation.com; 1st Edition. See page 32. 

  

16.       Safer Foundation©  “For more than 40 years, Safer Foundation’s mission has focused on reducing recidivism by supporting, through a full spectrum of services, the efforts of people with criminal records to become employed, law-abiding members of the community.”  

Retrieved from: http://www.saferfoundation.org (2014)

17.       A formal contractual process is essential to detail services delivered by a

professional RN.

[Written Contract Formats], (n.d.),

Retrieved from:

https://www.cnapro.com/pdf/MPLContractArticleandExampleContract_1-26-11.pdf

           

18.       “What is a Professional Service? To be considered as a professional service, procurement must meet certain criteria. Professional services are procured under a statutory exclusion, which establishes different methods of procurement. A contract, which is procured as a professional service, when in fact it is not a professional service, is subject to being voided.

A professional service is defined as a service that requires specialized knowledge and training (often through long and intensive academic preparation) or in-depth experience in a particular field or discipline.

Professional services are professional, technical, or consultant services predominantly intellectual in nature. They may include analysis, evaluation, predicting, planning, or recommendation and usually result in the production of a report or completion of a task.”

[Definition of a Professional Service], (n.d.),

Retrieved from: http://doa.alaska.gov/das/Procurement/profsvcs.html           

                       

19.       “GSA’s Federal Acquisition Service (FAS) is developing a next generation contract vehicle for complex professional services. The vehicle will be designed to address agencies’ needs for professional service requirements that:

                        Span multiple professional service disciplines;

                        Contain significant IT components, but are not IT requirements in and                                                 of themselves;

                        Contain Ancillary Support components commonly referred to as                                               ODCs;

                        Require flexibility for all contract types at the task order level                                                   including cost reimbursement; and

                        Any one or combination of all of the above.

OASIS will be able to provide both commercial and non-commercial services. The core disciplines of the contract will include program management services, management consulting services, logistics services, engineering services, scientific services, and financial services. We will engage federal agencies and Industry in a collaborative process to identify the most advantageous structure for this contract and the best   practices to incorporate into its design. Our goal is to create a contract vehicle that provides a total solution to agencies’ requirements while            maximizing opportunities for small businesses.”

[Federal Government’s Use of Professional Services Contracts], (n.d.), 

Retrieved from:

http://www.gsa.gov/

                                                                                                                                                            

20.       Hardy, C.L. (eHow Contributor)“How to Become an Independent Nurse            Contractor”

 “Independent nurse contractors partner with facilities like home health providers, hospitals, rehabilitation centers and doctor’s offices to provide       hourly nursing support. As an independent contractor, these nurses take on the responsibility and liability of entrepreneurship, which affords them, job flexibility and convenient scheduling as they select and negotiate the terms of their contract with each facility. While this career channel requires strong      business management acumen in addition to nursing licensing and expertise,           becoming an independent contractor can be a desirable nursing career for professionals seeking career autonomy.”

 [Description of how to become an Independent R.N. Contractor], 2014, Retrieved from:

http://www.ehow.com/how_6235034_become-independent-nurse-contractor.html

21.       Bemis, Patricia A., RN, CEN, “The outlook for nurses as independent contractors’’ (2008)

 “Some self-employed RNs provide nursing care to patients, directly or indirectly. These professionals are commonly referred to as “independent contractors” or as     “RN providers” in the insurance world. The nursing care an RN can provide is defined by each individual state nurse practice act”.

22.       Example Contract

[Contract Format for Independent Nurse Contractors], (n.d.),

Retrieved from:

https://www.cnapro.com/pdf/MPLContractArticleandExampleContract_1-26-11.pdf

23.       Most states have added a position statement to their nurse practice acts referencing holistic nursing, a specialty recognized by the American Nursing Association. For more information regarding Holistic Nursing standards and practices, see:

 [American Holistic Nursing Association], (n.d.),

Retrieved from:

http://www.ahna.org/

                         

24.       “Medical care still needs an order from a physician, unless the clinician is a nurse practitioner in a state that does not require physician supervision.

Options for independent contractors:

An RN may contract with the patient or the patient’s representative directly to provide services in the client’s home or, less frequently, within an established healthcare setting. Historically known as “private duty” nursing, these services are not covered by most insurance carriers. Since many patients today are unable to personally pay for nursing care, this option is often reserved for individuals, like celebrities, who can afford the services of a registered nurse.

In certain states, an RN can contract with the state Medicaid system and become an RN provider. Services are provided to Medicaid patients, and the program picks up the fee for the nursing care. Some stores are offering office space to nurse practitioners in hopes of attracting healthcare consumers. An NP or holistic NP can open an office and treat patients either independently or under the supervision of a physician. As is the case with a physician’s office, the patient or an insurance company pays for the nursing care. Nurse practitioners who apply to become Medicare RN providers—and bill according to its codes—will have some of their services covered under the federal       program.

An RN who owns a supplemental staffing firm or home health agency also can perform direct patient care. But he or she must be hired as an employee before delivering services.

An increasing number of RNs are becoming “wellness coaches” as more insurance plans implement wellness programs for employees. Particularly popular with the Baby Boomers, this option extends beyond traditional corporate initiatives. Some patients are hiring their own wellness coaches to help them stay well and active.”

[Functions of an R.N. Contractor], (n.d.),               

Retrieved from:

http://www.modernmedicine.com/modern-medicine/news/self-employed-nurses-and-patient-care#sthash.Ob2mC58d.dpuf

25.       HIPPA refers to the Health Insurance Portability and Accountability Act of 1996 (HIPPA). “The HIPAA Privacy Rule provides federal protections for individually identifiable health information held by covered entities and their business associates and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of health information needed for patient care and other important purposes.”

[Federal Government’s Definition of the Health Insurance Portability and

Accountability Act (HIPPA)], (2014),         

Retrieved from:

http://www.hhs.gov/ocr/privacy/

26.       Multiple articles describe ways a professional RN may become a RN Contractor.

[Multiple Articles Describing  “Registered Nurse Contractors”], 2014,

Retrieved from: https://www.google.com/search?client=safari&rls=en&q=registered+nurse+contractors&ie=UTF-8&oe=UTF-8

 

Licensure

Accreditation

Certification

Function

Education

Referral

Setting

Payment

Plan

Holistic Nursing

RN

American Holistic Nurses Assoc.

(AHNA).

American Holistic Nurses Certification Corp.

Clinical

Care

B.S.

&/or

M.S.

Experience.

MD

Medical Office

Clinic

Hospital

Employee -

Employer

Yes

Intensive Case Manager

RN

   

Case

Management

B.S.

&/or

M.S.

Experience.

MD

Community

Employee -

Employer (Independent

Practice Option)

Yes

Advanced Practice Nurse (APRN)

RN

Accreditation Midwifery Education (ACME).

Council on Accreditation of Nurse Anesthesia Educational Programs (COA).

American Association of Nurse Practitioners (AANP).

American Midwifery Certification Board (AMCB).

Certified RN Anesthetists (CRNA).

American Nurses Credentialing (ANCC).

Midwife,

Anesthetist,

Consultant,

Educator,

Researcher,

Practitioner.

M.S.

&/or

PhD

Experience.

MD

MD

MD

Assigned

Assigned

Proposal

MD

Clinic

Office

Hospital

Gov Agency

University

University

Clinic

Office

Employee -

Employer

Yes

Yes

Yes

Yes
Yes

Yes

Yes

Yes

Yes

Yes

Nurse Consultant

RN

   

Assessment,

Consultation,

Program Development,

Evaluation.

M.S.

&/or

PhD.

Experience.

   

Employee -

Employer (Independent

Practice Option)

 

Information sources include AHNA Standards of Holistic Nursing Practice (2000), Advanced Case Management (1993), Advanced Practice Nursing (2013), Criticial Ingredients of Intensive Case Management (1999).

                       

 

Licensure

Accreditation

Certification

Function

Education

Referral

Setting

Payment

Care Plan

&/or

Protocol

                   
                   

Holistic Nursing

RN

American Holistic Nurses Assoc.

(AHNA)

American Holistic Nurses Certification Corp.

 Clinical          

Care

B.S.

&/or

M.S.

(Plus experience)

MD

Medical Office

Clinic

Hospital

Employee -

Employer

Yes

                   

Intensive Case Manager

RN

   

Case

Management

B.S.

&/or

M.S.

(Plus experience)

MD

Community

Employee -

Employer (Independent

Practice Option)

Yes

                   

Advanced Practice Nurse (APRN)

RN

Accreditation Midwifery Education (ACME)

Council on Accreditation of Nurse Anesthesia Educational Programs (COA)

American Association of Nurse Practitioners (AANP)

American Midwifery Certification Board (AMCB)

Certified RN Anesthetists (CRNA)

American Nurses Credentialing (ANCC)

Midwife,

Anesthetist,

Consultant,

Educator,

Researcher,

Practitioner.

M.S.

&/or

PhD

(Plus experience)

MD

MD

MD

Assigned

Assigned

Proposed

MD

Clinic

Office

Hospital

Gov. Agency

University

University

Clinic

Office

Employee -

Employer

Yes

Yes

Yes

Yes
Yes

Yes

Yes

Yes

Yes

Yes

                   

Nurse Consultant

RN

   

Assessment,

Consultation,

Program Development,

Evaluation.

M.S.

&/or

PhD.

(Plus experience)

   

Employee -

Employer (Independent

Practice Option)

 
                   

Nurse Contractor

RN

     

B.S.

(Plus experience)

   

Gov’t/Agency

Contract