DEFINITION of Case Management

Case management  is the planning, processing and monitoring the healthcare services given to a patient by a coordinated group of healthcare providers. Case management is designed to provide for a patient’s needs while controlling costs, with a case manager maintaining information on a patient’s outcomes. Insurance companies, hospitals, and outpatient care providers may all assign a case manager to monitor a particular patient.

BREAKING DOWN Case Management

A medical professional managing an individual’s needs is not that different from a financial advisor managing a client’s portfolio. Case managers evaluate a patient’s needs, and determine how to provide care efficiently given the resources at hand. Because case managers work for health insurance companies, hospitals, and other providers, they attempt to keep costs down as much as possible.

How Case Management Works

The case management process begins when a new case is “opened”. A case manager evaluates what services are considered medically necessary, and works with different service providers to ensure that the required services are being given in the appropriate setting. Case managers must navigate complex care needs, which may involve different services being offered at different times by different healthcare providers. Hospital case management involves working with insurance companies to ensure that procedures and services fall under the policy coverage and will be paid for. It also involves educating patients on lifestyle adjustments, how to take medication, and when to come in for follow up appointments.

Case management does not end when a patient leaves the hospital. Insurance companies plan for ongoing medical needs, including further check-ups and outpatient care, in order to reduce the need for expensive emergency room visits. By expanding the time frame considered part of the case, medical providers are better able to catch symptoms early on before they develop into something more serious. Continued interaction with the patient also allows medical professionals a chance to evaluate how well treatments are progressing, and to change medication and visits as needed.

"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," according to a report by the American Institute of Healthcare Professionals.