CASE MANAGER ROLE

The certified case manager is a health care professional who incorporates the theory and practice applications of case management into the clinical role.  Case management is a care delivery model that is focused on managing the components of care for patients within or across the continuum of care, with the goals of achieving quality care outcomes and financial appropriateness.  A case manager oversees the processes of care delivered to patients, works collaboratively and provides leadership to the health care team, and is committed to the organization’s goals for professional case management services.  A case manager has often been referred to as the “captain of the ship,” as their role is designed to provide both leadership and management to the patients’ care plans.  They are the coordinators of patient care delivery, as well as the patient advocate and quality and costs experts of the health care team.

Overall, the role includes the care components of patient assessment, planning of care, coordinating and facilitating care plans for patients, working within and across the continuum of care, evaluating care provided, reassessing, mapping of care , evaluation, cost and quality containment strategies and patient advocacy.  Case management may also be referred to as care management or disease management; although disease management is often a unique model of care management.

The role is most often undertaken by registered nurses and social workers. Some physicians practice in case management, as well as other allied health care professionals. The role is very broad today in health care delivery as the role is really defined more by the needs and goals of individual organizations, versus one consistent role model of case management practice.  The mission of the organization drives the details of the role model of care management.

Certified case managers must be educated and be able to apply the theory and concepts of case management regardless of the setting of the practice or the job description defined by an employer. Education programs are designed to be comprehensive for this purpose.

WHERE DO CASE MANAGERS PRACTICE?

Case managers practice in health care organizations/agencies throughout the health care continuum. They can be seen in practice in any settings where health care is delivered from acute care to home care and hospice care. Case managers also are employed within the health care insurance industry and provide many components of case management within those systems. There really is nowhere in health care delivery today that a case manager cannot practice.

GENERAL COMPONENTS AND ROLE ACTIVITIES

As mentioned, the role of the case manager is often broad based, but can be narrowly focused as well. This varies from organization to organization.  Some of the major role components include:

• Providing care team management, leadership and coordination
• Coordinating patient care within or throughout continuums of care
• Providing assessments of patients, including clinical and psychosocial
• Works with the entire health care team to achieve the goals and expected outcomes for patients
• Oversees the patients’ plans of care while the patient is receiving care
• Provides frequent reassessments and evaluations of patient care received
• Collaborates and facilitates needed changes to the overall plan of care
• Collaborates with social services to define patient’s needs and assists in plans for social service care
• Ensures that treatment plans are appropriate for patients and coordinates treatment planning  with the client’s insurance company or other payers
• Works with DRG’s as well as utilization review methods and tools to guide appropriate patient care
• Evaluates the interventions of the patient care treatment team related to established cost and quality goals for care
• Serves as an advocate for the patient within the health care system, as well as with outside agencies such insurance companies and other payers
• Provides patient teaching to clients and families/significant others as defined by need
• Works closely with health insurers and other types of payers to oversee plan benefits for patients
• Assists and advises the organization in the development of policies and procedures that will guide safe and effective quality of care outcomes
• Coordinates the movement of patients from one continuum of care to another
• Participates in discharge planning for patients
• Participates on quality of care reviews within the organization and with outside agencies
• Coordinates the patients ongoing care in conjunction with outside agencies as needed
• Participates on quality of care committees and is an active participant in the development of quality care initiatives
• Educates members of the health care team on issues related to costs and cost containments, as well as the benefits plans for patients
• Participates in studies and research related to patient outcomes as well as studies that support evidence based practices in health care
• Oversees that unnecessary health care costs and over utilization are avoided
• Contributes to the ongoing evolution of the role as the external health care environment transforms
• Ensures the ethical and legal issues related to patient care delivery are addressed and that care is provided appropriately
• Works closely with or within managed care organizations

The above highlights core components of the role of the professional, certified case manager. Again, the role is often unique to the particular practice setting as well as in alignment with the organization that the case manager is practicing in.  The role is static and may change according to changing needs of organizations as well as changes in the models of health care delivery .  We see the role as a role that evolves as changes in health care delivery systems emerge and dictate.

Are you interested in becoming a Certified Case Manager? If this practice specialty interests you then please review our program and feel free to speak with our advisors regarding our complete education program and courses leading to qualifications to achieve the certification/Fellowship.