A MULTIDISCIPLINARY APPROACH TO DEVELOPING AN INDIVIDUALIZED CARE PLAN IN THE PRACTICE OF THE RN CASE MANAGER

Abstract

The increasing complexity of patient care in home health settings has led to a growing need for coordinated, patient-centered approaches. Registered Nurse (RN) Case Managers play a pivotal role in developing and implementing individualized care plans that reflect the unique medical, psychological, and social needs of patients. This thesis explores the application of a multidisciplinary approach in the development of such plans, highlighting the RN Case Manager’s role as a central coordinator in the continuum of care. The purpose of the study is to investigate how RN Case Managers collaborate with physicians, therapists, social workers, and caregivers to ensure comprehensive and efficient care planning. The research examines the processes, benefits, and challenges of interprofessional collaboration and evaluates the impact of multidisciplinary planning on patient outcomes and care continuity. A mixed-methods design was employed, combining qualitative interviews with RN Case Managers and quantitative analysis of care outcomes in a home healthcare setting. Findings indicate that multidisciplinary collaboration significantly enhances the effectiveness of individualized care plans, fosters better communication among healthcare providers, and leads to improved patient satisfaction and health indicators. The study concludes with practical recommendations for strengthening the multidisciplinary approach in nursing practice and offers strategies for training RN Case Managers in effective team-based care coordination. These findings contribute to the ongoing development of holistic, evidence-based practices in community and home-based nursing care.