Question:

What is case management and how can one help me?

Answer:

 The American Nurse Case Management Association defines case management as “Case Management in health care delivery systems is a collaborative practice including patients, caregivers, nurses, social workers, physicians, payers, support staff, other practitioners and the community.”  

The Case Management process helps ensure communication and care coordination along a continuum of care through effective transitional care management. “Recognizing the patient’s right to self-determination, the significance of the social determinants of health and the complexities of care, the goals of Case Management include the achievement of optimal health, access to services, and appropriate utilization of resources.” This means that case managers who are usually nurses or social workers work in many different health care settings with the goal of helping patients transition from the emergency room to inpatient care, to inpatient rehabilitation to outpatient rehabilitation and home. Their goal should be to ensure that the patient, as they are able at the time, and the family participate in the process of care decision making by including them in discussions of care or rounds, educating them about the illness and patient’s needs as well as what their insurance coverage will or will not cover. The case manager may be a certified nurse case manager, or a social worker, they will meet with other staff members and assist the family in understanding the illness, treatments, and the care needs both while in the hospital and after discharge. Nurse case managers are knowledgeable about understanding insurance coverage and can help the patient and their family understand their insurance policy and the coverage of care. They are also knowledgeable about resources available that can assist individuals in a variety of ways including payment of care, resources in the community, and how available assistive programs work and how to apply for them. Although some case managers work for insurance companies their goal should not only be reduction of cost but also quality of care and assurance of the best quality of life is possible for the patients they serve.

In order to obtain case management services, one can ask at their provider’s office, most doctors who practice in major medical centers, have access to case management services. Another option is to ask for case management services through a rehabilitation facility if you have received services there. Insurance companies also often will assign nurse case managers to patients with complex illnesses or at a patient’s request. If you are asking for case management services it is often helpful to the nurse case manager to know what help you need. Do you need  help coordinating appointments and care? Is it finding assistance in finding care at home, rehabilitation services or cognitive rehabilitation? The nurse case manager may do a full assessment of your case so that they know how to best help you. They may review your hospital records, this will help them to make sure that you get the correct services and provide them with the information they need to provide the insurance company to make sure that those services are covered by insurance. They also may know of local services that were not previously identified but that you may find helpful. The main goal of case management is helping patients and their families navigate their healthcare journey. In order to effectively do that, case managers need to not only be able to work with all other health care providers but also to be aware of the individual’s goals. 

 For further assistance, see the IAES handout, Who’s Who on Your Medical Team

References:

Implementation of nursing case management to improve community access to care: A scoping review

Case Management