What Is Case Management in Health Care?

When a patient is hit by a devastating illness or injury, she may not know where to turn for help. Many families with no medical background do not know what questions to ask, nor do they understand the answers given. A case management nurse assigned to a patient's case ensures the appropriate facility, level of care, course of treatment and ancillary services are being used. He also explains the condition and treatment options to the patient and her family. The primary goal of case management is to get the maximum benefit and highest quality of care for a patient.

Origins

• Medical advances have increased survival rates among ill and injured patients. Insurance companies developed case management departments to monitor high-dollar cases. A large portion of a case manager's job is to document the patient's illness or injury and subsequent course of treatment. Although this role was originally meant to control the spiraling costs of catastrophic cases, case managers advocate for the patient as well.

Catastrophic Cases

• Long-term illnesses or injuries requiring extensive rehabilitation are considered catastrophic. A case manager may "borrow" benefit dollars to pay for services not normally covered. If a patient needs a specialized wheelchair or nutritional supplements, his case manager figures out how to get them. Catastrophic cases can easily exceed the limits of a health plan. When diagnosed with a catastrophic illness, a patient may become "uninsurable"; if she loses coverage, she must rely on state or federal programs. A case manager may provide options for continuing coverage.

Levels of Care

• Within a hospital there are several levels of care, including intensive care, acute care, rehabilitation and long-term care. A patient may receive physical therapy, occupational therapy and other ancillary services. Catastrophically injured patients often must relearn daily living tasks or learn to get around in a wheelchair.

Evaluation

• A case manager reviews a patient's case with his doctor and determines if he is well enough for home care, sick enough for hospitalization, or may benefit from a nursing home, convalescent hospital or hospice. Case managers can arrange training for family members, which allows the family to be as involved in daily care as they wish.

Benefits

• By identifying catastrophic cases early, case management can help patients obtain the highest quality of care while saving benefit dollars for future care. Hospitals have case management departments that work with patients and their families to ensure a high quality of care is received. When family members do not have a medical background and do not understand different treatment options or levels of care available, a case manager can facilitate communication.