Hospital case management involves working with insurance companies to ensure procedures and services are covered and paid for. This also includes educating patients about lifestyle adjustments, taking medications, and when to come for follow-up appointments. Case management in a rehabilitation centre, for example, would involve psychiatric service providers to monitor patients. The clinical case management model involves a case manager (often a therapist or counsellor) assigned by a clinical service provider. The case manager works directly with the client in a clinical capacity, providing care and coordinating and developing treatment plans. Such direct collaboration has the potential to improve the client`s health outcomes and encourage them to follow their care plan more directly. With input from the patient and family, the home care case manager develops the patient`s care plan and submits it to the patient`s physician for final approval. The case manager also coordinates the implementation of the plan with the client and service provider and makes adjustments to the plan if necessary. First, you should know that what a case manager does depends on the environment in which they work. For example, a case manager who works for a home health care company will provide very different services than a case manager from a health insurance company, workers` compensation insurance or hospital. Case management is intrinsically rooted in multidisciplinary communication and teamwork due to its emphasis on coordination. [8] An effective case manager must facilitate communication across disciplines in order to develop a care plan that encompasses the many areas typically involved in a patient`s care.
It is particularly important in patients/clients with chronic diseases or in situations where they use health services frequently. The case manager must interact with a variety of patients/clients from different backgrounds, possess a wide range of skills, and access different levels of support for families and communities. The underlying premise of case management is that when a person achieves the optimal level of well-being and functioning, everyone benefits: the people being treated, their support systems, health systems and the various sources of reimbursement. Case management encompasses a wide range of activities; As a result, it is difficult to accurately define case management as a separate intervention. In addition, variability in the definition of case management and the clinical environment in which case management takes place are also important. In their review of 79 articles, Lukersmith et al. identified a variety of service areas and service settings that use case management. [5] The service sectors include health, social services, penitentiary, professional, veterans and law. Service settings include public, private, and non-governmental organizations, which can be overlaid based on the number of resources and support. [5] Targeted case management targets a specific group of patients who require ongoing care, such as patients with chronic mental health problems or disabilities. In some health insurance companies, work may focus on a specific chronic illness. For example, if you are working with people living with HIV, the case manager will ensure that monthly medications are taken correctly, adherence is optimal, routine blood tests are scheduled, and side effects or complications are detected so that providers can be coordinated.
By extending the time frame considered part of the case, medical providers can detect symptoms early before they turn into something more serious. Ongoing interaction with the patient also allows healthcare professionals to assess treatment progress and modify medications and visits as needed. Case management is a multi-phase process that requires a single interface between health knowledge and interpersonal skills. In this section, you`ll learn more about what you can expect from the case management process, the skills you`ll need, and an example of case management in action. In this context, any failure in case management can have direct and potentially serious consequences for the patient. The goal of health insurance case management is to ensure that the patient receives medically necessary care and quality care, and that care is provided as efficiently and economically as possible. The case manager also anticipates the patient`s future health needs and tries to put in place mechanisms to meet those needs as effectively as possible. At the most basic level, health care case management is about providing valuable care to patients who need it. If you are planning your future career as a case manager, you may want to consider a flexible, low-cost online course to gain important professional skills and better understand the patient experience.
The University of Houston`s Value-Based Care specialization introduces students to the fundamentals of value-based care, such as the role of case management and the power of effective communication to improve health outcomes for patients and healthcare professionals. Case management is defined as a health care process in which a professional helps a patient or client develop a plan that coordinates and integrates the support services the patient/client needs to optimize potential health and psychosocial goals and outcomes. [1] The case management process helps the patient and family navigate a complex set of services and supports within a benefit plan, agency or facility, and their community. In terms of cost-effective analysis of outcomes, Hudon et al. found that about 10% of patients account for about 70% of all healthcare expenditure. [1] Statistics show that 5% of emergency room patients account for 30-50% of emergency room visits, and these high-capacity patients may unsuccessfully attempt to meet their own health care and related needs, which is often inefficient, characterized by overuse of expensive or underutilized health services and effective uncoordinated social services. [1] [2] Three main case management models are used in health care. While each focuses on providing clients with the care they need, each also has its own unique purpose. Nevertheless, a case manager may use a combination of these models in their own practice, depending on their client`s needs and the professional work environment. Social work case management is how a professional social worker assesses and supports a client and their family. A social worker can manage a case by conducting home visits, helping a client register for the social services they need, and following up with a client and family after an assessment.
If you want to become a case manager, you must meet the education, licensing, and certification requirements of your state and the particular organization you want to work for (e.g., an insurance company, hospital, home care company, etc.). In most cases, you`ll need training in a field like nursing or social work, but the details will vary depending on the job you`re looking for. Nurse case managers, for example, are registered nurses (RNs) who use their medical expertise to help patients maneuver the health care system and health insurance to receive appropriate care. The brokerage case management model involves a case manager who assesses a client`s needs and then acts as a broker by connecting them with relevant resources, services and health professionals. Typically, case managers in this system have little personal contact with the client and act instead as liaison officers to ensure that the client receives the care they need. This model places less emphasis on tracking outcomes and more on connecting clients with the health professionals who will do so. If you`re not sure what a case manager does, why you need one, or want to become one, this article explains some basic information you need to know. Case management services are best optimized when delivered in an environment that allows for direct communication between the case manager, client, payer, primary care provider and other service delivery professionals.