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PROVIDER GUIDE TO CASE MANAGEMENT

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

WHAT OUR CASE MANAGERS DO:

Help providers:

  • Establish Home Health Services
  • Facilitate placement in alternate levels of care
  • Coordinate/schedule needed therapies
  • Complete outpatient disposition planning
  • Order/procure durable medical equipment
  • Coordinate in-depth psycho-social assessment

CASE MANAGERS PROVIDE VALUABLE INFORMATION…

Case Managers obtain information about the home environment regarding barriers to recovery. Case Managers also evaluate family dynamics and the family’s impact on the patient’s response to treatment. Progress towards treatment goals and the need for additional education and/or clarification of information is monitored continuously. In addition, Case Managers review specifics related to insurance coverage in relation to identified medical needs. Finally, Case Managers assess the patient’s/family’s attitude and degree of motivation toward achieving optimal functioning.

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.

HOW LONG WILL CASE MANAGEMENT SERVICES LAST?

Case Management is a goal-directed practice. Some patients require help for an extended period of time. Most patients, however, will not need assistance once they have achieved their goals. Case Management cases will be closed when:

  • A treatment plan is in place and the patient is able to function independently
  • There is a hiatus in the disease process or medical services are no longer needed
  • Treatment goals have been met
  • Unable to reach patient or refusal of services by patient
  • The patient is non-participant or repeatedly non-compliant in the Case Management treatment plan
  • Patient has exhausted medical benefits or is no longer eligible for benefits
  • Patient has ETS, PCS, moved out of area, or makes a PCM change to a network provider
  • Patient death