Developing a Case Management Plan

Developing a Case Management Plan


Developing a Case Management Plan

Jimmy Jansen is a 44-year-old man with type 1 diabetes mellitus. He was recently referred to your home health agency for case management follow-up at home. He is experiencing multiple complications from his diabetes, including the recent onset of blindness and peripheral neuropathy. His left leg was amputated below the knee last year because of a gangrenous infection of his foot. He is unable to wear his prosthesis at present because he has a small ulcer at the stump site. His chart states that he has been only “intermittently compliant” with blood glucose testing or insulin administration in the past despite the visit of a community health nurse on a weekly basis over the past year. His renal function has become progressively worse over the past 6 months, and it is anticipated that he will need to begin hemodialysis soon.

His social history reveals that he recently separated from his wife and has no contact with an adult son who lives in another state. He has not worked for more than 10 years and has no insurance other than Medicaid. The home he lives in is small, and he says that he has not been able to maintain it with his wife gone. No formal safety assessment of his home has been conducted. He also acknowledges that he is not eating right because he now must do his own cooking. He cannot drive and states, “I don’t know how I’m going to get to the clinic to have my blood cleaned by the kidney machine.”

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Mr. Jansen has many problems that would likely benefit from case management intervention.

1. Make a list of five nursing diagnoses for Mr. Jansen that you would use to prioritize your interventions.

2. Then make a list of at least five goals that you would like to accomplish in planning Mr. Jansen’s care. Make sure that these goals reflect realistic patient outcomes.

3. What referrals would you make? What interventions would you implement yourself? Would you involve other disciplines in his plan of care?

4. What is your plan for follow-up and evaluation?

• List which Learning Exercise you are solving at the start of your analysis and provide a brief summary of the case. Be sure to apply an appropriate problem-solving/decision-making model (Traditional Problem-Solving Process, Managerial Decision-Making Model, The Nursing Process, or the Integrated Ethical Problem-Solving Model) in determining what you should do. Justify your decision with supporting evidence






Nursing Diagnosis for Mr. Jansen

  1. Higher risk of unstable blood glucose
  2.  Deficient knowledge related to the management of type 1 diabetes
  3.  Risk for infection
  4. Imbalanced nutrition
  5. A high risk of ineffective therapeutic regimen management (Cárdenas-Valladolid et al., 2018)

5 Goals to Accomplish Related to Mr. Jansen’s Care

  1.  To normalize insulin activity of the patient, including normalizing their blood glucose level so as to reduce or prevent the development of any complications that may be vascular or neuropathic in nature.
  2. Provide patient education and ensure that the patient is adequately empowered to adhere to the best treatment regimen for type 1 diabetes.
  3. To demonstrate various techniques and changes to the patient’s lifestyle, which can help prevent the onset of infections and to identify various interventions to reduce the risk of infection on the patient.
  4. To ensure that the patient ingests the appropriate amount of nutrients and calories daily and to ensure that the patient displays their usual energy levels.
  5. To ensure that the patient displays adequate knowledge of various self-care measures related to diabetes and to ensure that the patient is able to effectively verbalize the potential complications related to diabetes in the diabetes disease process (Anderson & Moore, 2017).

Referrals and interventions

To effectively treat the patient with type 1 diabetes mellitus, I would only refer the patient to a nephrologist who would help to assess his renal function and to conduct hemodialysis.

On the other hand, I would implement several interventions on the patient with type 1 diabetes mellitus as their case manager. This would include adopting interventions to normalize the insulin activity of the patient and their blood glucose level, adopting interventions to educate the patient effectively on issues related to type 1 diabetes, and providing interventions to change the patient lifestyle to avoid the risk of infections. I would also add up interventions to ensure that the patient receives a healthy diet and is adequately educated on issues related to type 1 diabetes (Cárdenas-Valladolid et al., 2018).

The first intervention I would implement as a case manager for the type 1 diabetes patient would be to stabilize the patient’s glucose. I will therefore assess the patient for hyperglycemia and assess the patient’s blood glucose levels before meals and at bedtime, monitor the patient’s weight daily, and monitor the patient’s glycosylated hemoglobin. I would then administer insulin consistently to the patient and also teach the patient how to perform effective glucose monitoring at home. I would also educate the patient on how to take insulin as directed.

On the other hand, the second intervention I would conduct on the type 1 diabetes patients would be to adequately educate the patient on all issues related to type 1 diabetes and to ensure that the patient understands the symptoms of low blood glucose levels, adequate insulin injection and the treatment of hypoglycemia and the diet they would need to take (Anderson & Moore, 2017).

The word intervention I would conduct on the type 1 diabetes patient would be to educate the patient on various interventions they would utilize to avoid the risk of infection, such as the gangrenous infection he experienced in the past. To avoid infections, the patient will therefore need to change his lifestyle and come up with a specific strategy to reduce the risk of infections (Anderson & Moore, 2017).

On the other hand, I would involve a nutritionist in the type 1 diabetes patient’s plan of care. The nutritionist would help to develop an adequate food plan for the patient and to ensure that the patient follows the suggested food plan (Anderson & Moore, 2017).

 Plan for Follow-Up and Evaluation

Mr. Jansen would need to visit the home health agency every two weeks for evaluation and follow-up of his progress in managing type 1 diabetes.


Anderson, N. T., & Moore, E. P. (2017). A Clinical Practice Lifestyle Intervention for Type 2 Diabetes. The Journal for Nurse Practitioners, 13(1), e35–e38.

Cárdenas-Valladolid, J., López-de Andrés, A., Jiménez-García, R., de Dios-Duarte, M. J., Gómez-Campelo, P., de Burgos-Lunar, C., San Andrés-Rebollo, F. J., Abánades-Herranz, J. C., & Salinero-Fort, M. A. (2018). Effectiveness of standardized nursing care plans to achieve A1C, blood pressure, and LDL-C goals among people with poorly controlled type 2 diabetes mellitus at baseline: four-year follow-up study. BMC Family Practice, 19(1).