Case Management is a dynamic and systematic collaborative process in which a professionally licensed provider (usually a nurse or social worker) assess, plans, coordinates, implements, monitors, advocates for and evaluates the options and services required to meet an individual’s unique healthcare needs.
What is Case Management?
Case management involves a team of health care professionals who help you and your family solve your medical, educational and social needs. The case manager is your team coach.
You and the team work out a plan to help you gain control of your illness, injury, or situation as soon as possible. You will also plan with them to get the right help for what you need as you improve. The case manager will oversee the plan with you to be sure it continues to meet any change in your health status. The goal is to help smooth your trip through the maze of medical care.
Who are Case Managers?
Case managers are usually nurses or social workers who can help you and your family figure out complex health care and support systems. They will work with you to coordinate the services and other community resources you need
They can help:
• Provide advocacy, support, and education
• Reduce burden and streamline appropriate utilization of care
• Partner with members of your healthcare team to assist in coordination of your healthcare needs
• Monitoring for progress and desired outcomes
Who is a candidate for Case Management?
Usually people with very complex conditions or situations require case management. These may
be of a medical, social, financial, or mental health nature. Some examples are listed below. Participation is always voluntary.
• Catastrophic illness or injury
• 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
Why Would I Need Case Management?
The need for case management services is determined through a collaboration between you, your family or caregiver, your health care team, and your provider. This collaboration will include a comprehensive assessment of your health, psychosocial needs, and use of health care services and resources.
Case management can help by:
• Coordinating your care.
• Assessing, planning, and facilitating services for you.
• Evaluating your options.
• Advocating on your behalf.
You or your family member may need case management if you have:
• Instability with chronic health problems
• A serious terminal illness
• An increased need for different provider specialties due to multiple diseases or conditions
• A need for more support and education during a critical period
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 CRDAMC, the Inpatient Case Managers are available on the 5th and on the in-patient wards to assist with any discharge planning needs.
The Role of the Inpatient 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 allowing patients to smoothly transition to the next level of care while keeping costs to the patient at a minimum.
Discharge Planners do not make diagnoses 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
The Provider and Discharge Planner work together to ensure that patients move onto another level of care:
• Home care
• Out-patient care
• Alternate acute care
Discharge Planners are available in the following inpatient areas:
Inpatient Psychiatric Service (5 East)
Medical-Surgical Unit (3 South)
Mother & Baby Unit (MBU)
Neonatal Intensive Care Unit (NICU)
Pediatrics (4 East)