Related Experiment Video

Updated: Apr 25, 2026

Methodology for Establishing a Community-Wide Life Laboratory for Capturing Unobtrusive and Continuous Remote Activity and Health Data

Methodology for Establishing a Community-Wide Life Laboratory for Capturing Unobtrusive and Continuous Remote Activity and Health Data

Published on: July 27, 2018

Care coordination in long-term home- and community-based care

Barbara Johansson¹, Jane Harkey

¹Barbara Johansson, BSN, RN, CCM, CPUM, is a Commissioner, Commission for Case Manager Certification, Mount Laurel, New Jersey. She is also Staff Vice President for a national managed care organization. Jane Harkey, RN, MSW, CCM, is a Commissioner, Commission for Case Manager Certification, Mount Laurel, New Jersey. She operates a private geriatric care management practice.

Home Healthcare Nurse

|August 30, 2014

Summary

Professional case managers are key to successful long-term home- and community-based care (HCBC). Their comprehensive assessments and care plans address all needs, ensuring optimal outcomes for individuals and families.

Area of Science:

Gerontology
Health Services Research
Case Management

Background:

Home- and community-based care (HCBC) is crucial for individuals needing long-term support.
Effective care coordination is vital for the success of HCBC.

Purpose of the Study:

To examine the role of professional board-certified case managers in successful long-term HCBC.
To highlight the importance of comprehensive assessments and care planning in HCBC.

Main Methods:

Utilized qualitative measurements for robust individual assessments.
Developed person-centered, evidence-based care plans.
Coordinated multidisciplinary teams, including informal supports.

Main Results:

Professional case management ensures thorough assessment of clinical, psychosocial, and environmental needs.
Comprehensive care plans address all identified needs.
Effective coordination with multidisciplinary teams is essential for HCBC success.

Conclusions:

Professional board-certified case managers are integral to successful long-term HCBC.
Rigor in care coordination from the outset is essential for achieving long-term HCBC goals.
A holistic, person-centered approach by case managers optimizes HCBC outcomes.

Related Concept Videos

Documentation in Long-Term and Home Healthcare Setting

Documentation in Long-Term and Home Healthcare Setting

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities

Continuing Care

Continuing Care

Continuing care describes the variety of health, personal, and social services provided over a prolonged period. The need for continuing care is increasing because people are living longer. Many people do not have families or others to care for them. Continuing care is mainly for patients who are disabled, functionally dependent, or suffering from a terminal disease. It is available within institutional settings or in homes. Examples include nursing centers or facilities, assisted living,...

Planning Nursing Care I

Planning Nursing Care I

The planning phase of the nursing process helps nurses set priorities, outline patient-centered goals and expected outcomes, and tailor nursing interventions to align with the aligned care plan. Through the planning phase, the nurse applies critical thinking skills to align and develop interventions according to the patient's needs. It provides continuity of care allowing patients to receive the maximum benefit from treatment. It serves as a pilot plan for allocating individual staff to a...

Restorative Care

Restorative Care

Restorative care is provided once a patient has been discharged from a healthcare facility and requires additional services. The additional services include home care, rehabilitation programs, and extended care. Restorative care centers help the patient regain their previous level of functioning or acquire a new level of functioning due to the incapacitating effects of a disease or a disability. It aims to assist patients in enhancing their quality of life by encouraging independence,...

Methods of Documentation VI: Case Management Model

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...

Specialized Care Centers and Settings-I

Specialized Care Centers and Settings-I

Specialized care settings or centers are situated in convenient locations within the community and offer care to a specific group or population. They consist of daycare facilities, mental health facilities, rural health facilities, educational institutions, industries, shelters for the homeless, and rehabilitation facilities.
Daycare centers
They provide several functions. Some facilities care for healthy newborns and children whose parents work, while others are medically focused and care for...

Articles linked to this work by shared authors, journal, and citation graph.

Supporting the Support System: How Assessment and Communication Can Help Patients and Their Support Systems.

Professional case management·2017

Meeting People "Where They Are": Case Managers Empower and Motivate Clients to Pursue Their Health Goals.

Professional case management·2016

Safety first for a homebound patient with dementia.

Home healthcare nurse·2014

See all related articles