A Case for Case Management

The saying “what’s old is new again” certainly applies to what has become known as “case management.” It provides old-fashioned healthcare in today’s high-tech world of medical tests and unfamiliar language.

In a large hospital, the sheer number of people coming and going can be confusing. But when circumstances allow for a case manager, the chaos often gives way to control.

“Patients and families dealing with chronic conditions can benefit from the services of case managers,” said Mary Perloe, an Adult Geriatric Nurse Practitioner.

Perloe said the service can close some serious communication gaps between care providers. Case managers can “maximize health education opportunities which might have been missed or lost,” she said

Certified Case Managers

Case management has its roots in public health nursing. The term came from “district nursing,” a service focused on caring for the ill and those living in poverty.

The American Case Management certification was created by the American Case Management Association in 2005. The credential of Certified Case Manager (CCM) is made available to licensed registered nurses and social workers. There are specific eligibility requirements before taking and passing the certification exam for either group.

Everyone will agree that the current health system can be very complex. For example, a patient can face 25 to 40 medical appointments in a matter of 90 days when first diagnosed with cancer or another serious medical problem.

In today’s complex hospital systems, case managers not only focus on illness, they also ensure chronically ill patients receive high-quality care in the least restrictive settings. With sky-high medical costs, their current role includes striving to achieve the most cost-effective treatment, whether patients are in or out of a hospital. What CCMs do

Case managers are there to assist clients who may not know where to turn in times of need. Take Carolyn Watson. She’s a registered nurse and certified case manager with Manley & Associates. She said that requests for assistance can run the gamut from long-term planning and support to limited short-term help.

“Family concerns are one time when we might receive a call to our office,” Watson said. “Sometimes, an adult child will be worried about an aging parent or other relative and will contact our company. They might want someone to make sure mom is on the right medicines once she’s been discharged from the hospital.”

Those calls often come from children who live far away.

Watson said that sometimes family members call because they’re concerned about a loved one who is still driving when they shouldn’t be. “‘How do I stop that from happening?’ is a frequently heard question among my colleagues,” she said.

Case managers can help follow up with patients and families who need help with legal parameters, Watson noted. “We also want people to go to the right resources for help,” she said.

At the same time, “we want to be sure the client’s rights are protected,” she said, adding that it’s important to know whether the client is in danger or the family is overly concerned.

Any number of circumstances can bring about the need to speak with case managers, and a CCM may be assigned at any stage in someone’s treatment. Clients should look for certification and a nursing or social worker’s education and background, along with current licenses.

Are Nurse Navigators also Case Managers?

Sometimes, a case manager might be referred to as a personal ‘nurse navigator.’ But “that happens more often with patients who have been diagnosed with cancer or heart disease,” Watson said. She agreed that the titles can be confusing.

Nurse navigators tend to have their certification in a specific medical specialty, she said. For example, one may be an oncology nurse navigator or a cardiac medicine nurse navigator. They may also have advanced nursing degrees, such as advanced practice nurse practitioner (APRN) but may not be a CCM.

“It’s simply a matter of semantics,” Watson said. “They do very much the same thing that case managers do.” However, she continued, their backgrounds are usually in specific areas of medical expertise—such as heart disease or cancer—and they’re typically based in doctors’ offices. “They specialize in working with patients whose diagnosis may require that kind of extra support,” she said.

Can Medicare help?

Medicare may pay for a healthcare provider’s help to manage prolonged support if the patient has two or more serious chronic conditions that are expected to last at least a year, according to Medicare’s website, medicare.gov.

Patients may pay a monthly fee, and the Part B deductible and coinsurance apply. If they have supplemental insurance, or have both Medicare and Medicaid, it may help cover the fee.

However, adding to the complications, Medicare’s name for the service differs a bit. Their Chronic Care Manager works with patients who have been diagnosed with chronic conditions, such as arthritis, asthma, diabetes, hypertension, heart disease, osteoporosis, mental health and other illnesses.

Benefits of using a CCM

The improvements nurse Perloe sees from case management include medication reconciliation and adherence, care coordination or more appropriate referrals to home- and community-based services. This kind of help makes life easier for the patient and often saves time and money for the provider, she said.

If patients or their families agree to case management through their healthcare provider or insurer, the case manager will prepare a patient care plan. In addition, they help with medication management, 24/7 access for urgent care needs and offer support when patients are being transferred from one setting to another, like when moving someone from a rehabilitation facility to their home.

Whether it’s helping with homelessness, developing independent living skills or finding treatment help for those with medical needs, case managers can be invaluable resources just when they’re needed most.