What Is Case Management?

The definition of case management is the planning, processing, and monitoring of 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.

Case management, sometimes known as dynamic case management, work is usually done by professionals in the healthcare field with experience in working in a medical setting such as a hospital.

Key Takeaways

  • The role of a case manager is most often undertaken by registered nurses and social workers.
  • Some physicians practice in case management, as well as other allied healthcare professionals.
  • The role is defined more by the needs and goals of individual organizations, versus one consistent role model of case management practice. 
  • The above information comes directly from a report by the American Institute of Healthcare Professionals.

How Case Management Works

How do you define case management? There are various ways. For example, 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. With rising costs in healthcare, case management can be a useful tool for both consumers and companies alike.

A case manager evaluates what services are considered medically necessary when a new case is started 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 in a rehabilitation center, for example, would use mental health service providers to follow up with patients.

The case management process begins when a new case is “opened.”

Special Considerations

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. Some nurses will visit patients in their homes even after a routine medical procedure like the birth of a child.

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.