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Outcomes Management



Mission and Vision

Mission

Support the Army mission, by ensuring high quality comprehensive healthcare to all beneficiaries with emphasis on prevention, cost effectiveness, & continuity, while fostering patient and family independence through education and support.

Vision

Medical Management… empowering independence; managing healthcare …planning for excellence.

Definition of Case Management

Case Management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet complex health needs through communication and available resources to promote quality, cost-effective outcomes. --Case Management Society of America, 2002

How Case Management Works

Assessment -The Case Manager evaluates the patient/family for services. Populations targeted include:

  • High cost cases
  • High risk cases
  • Complex/disease state management
  • Prevention
  • Wellness

Plan - The Case Manager:

  • Assists the patient in establishing a successful treatment plan
  • Provides relevant condition/disease mgt education
  • Goal is to assist pt/family in becoming independent in self-care and self-determinate in reaching/maintaining optimal health

Implementation - Case Management:

  • Improves patient/family appropriate access to care and services
  • Advocates for patient/family and facility services and cost effectiveness
  • Monitors the ongoing treatment plan for effectiveness

Coordinate - The Case Manager:

  • Coordinates the plan of care
  • Communicates any changes to the plan of care to the team, patient, and family
  • If needed, coordinates medical supplies, equipment, or in-home services

Evaluate – The Case Manager will evaluate:

  • Patient/family continued need for services
  • Response to the plan of care

Who is a Candidate for Case Management?

Any of the following may indicate the need for Case Management evaluation:

  • Catastrophic illness or injury
  • Chronic or terminal illness
  • Multiple medical problems
  • Functional/physical deterioration
  • Lack of family/social support
  • Non-compliance/resistance to treatment
  • Inability to follow treatment
  • Repeat admissions
  • Unexpected re-admissions
  • Multiple Emergency Department visits
  • Multiple providers

How to Enroll a Patient in Case Management

Contact your Clinic Case Manager directly.

Case Managers are available in the following clinics or areas:

  • Joel Health Clinic
  • Robinson Health Clinic
  • Clark Health Clinic
  • Byars Health Clinic
  • Hope Mills Medical Home
  • Fayetteville Medical Home
  • Linden Oaks Medical Home
  • Emergency Department
  • Family Practice Clinic
  • OB-GYN Clinic
  • TBI Clinic
  • Behavioral Health

Inpatient Case Management [Discharge Planning]

The government has established a Discharge Planning Program to help active duty and retired service members and their families to understand and access the healthcare system. At Womack Army Medical Center, the Discharge Planners are available on the second floor and on the in-patient wards.

The Role of the Inpatient Case Manager [Discharge Planner]

Inpatient Case Managers [Discharge Planners] are registered nurses who work with the medical staff and the patient to arrange extended care at home or in the community prior to discharge from the hospital. The discharge planner functions as a consultant for the discharge planning process within a health facility, providing education and support to hospital staff in the development and implementation of discharge plans. Discharge Planners coordinate all services that will allow patients to smoothly transition to the next level of care while keeping costs to the patient at a minimum.

**DISCHARGE PLANNERS DO NOT MAKE DIAGNOSIS OR TREATMENT DECISIONS.

The Discharge Planner will assess a patient’s needs; create a plan of care; educate the patient and their family, and help the individual to make the best decisions they can about their healthcare needs prior to hospital discharge.

Discharge planning may be helpful if you have:

  • Chronic or multiple health problems
  • A serious or terminal illness
  • More than one Provider for different specialties
  • Lack of family or community support
  • Difficulty following your Provider's plan of care

Discharge Planners may assist you in obtaining:

  • Home Health Services
  • Hospice Services
  • Occupational, Physical or Speech Therapy Services
  • Medical equipment, i.e. wheelchairs, oxygen, etc
  • Use of the TRICARE/Health Net system

Inpatient Case Management/Discharge Planning Services

Your Provider, the leader of your health care team, works closely with your Discharge Planner to ensure that patients move onto another level of care whether it is:

  • Home care
  • Out-patient care
  • Alternate acute care
  • Long term acute care
  • Nursing home care

Discharge Planners are available in the following inpatient areas:

  • ICU/SDU
  • NICU
  • 3 North - Pediatrics
  • 3 South - Mother/Baby Unit
  • 4 South - Medicine
  • 2 North - Surgery
  • 6 South - Psychiatry

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Telephone
Contact Information
Phone: 910-907- 1054
Department Chief

910-907-6233 or 910-907-8586
Senior Case Managers

910-907- 1084
Health Systems Specialist

910-907-1013
Management Analyst

910-907- 6905
Admin Assistant

Nurse Case Managers [Outpatient]

910-643-2116 or 910-643-2313
Behavioral Health

910-907-9762 or 910-907-9732
910-907-9705 or 910-907-8469
Clark Health Clinic

907-7972
Emergency Department

910-907-7726 or 910-907-8404
Family Medicine Clinic

910-907-8504
Off-Home Case Managers

910-907-9199 or 910-907-9054
Joel Health Clinic

910-570-3214 or 910-907-7050
Byars Health Clinic

910-907-6945 or 910-907-6973
910-907-6767
Robinson Health Clinic

Inpatient Nurse Case Managers
[Discharge Planners]


910-907-8257
Mother-Baby/Peds/NICU

910-907-7438
Surgery, 2N

910-907-9178
Medicine, 4S

910-907-9261
Step-Down/ICU

910-907-7717
Placement/Transfers
Location: Bldg 4-2817 Reilly Rd
Ft Bragg NC 28310