Nurse Case Management

What is Case Management?

Case Management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet complex health needs through communication and available resources to promote quality, cost-effective outcomes. - Case Management Society of America, 2002.

A Case Manager is your team coach. Together, you develop a plan to promptly control your illness, injury, or situation and to navigate through the maze of medical care to your recovery goal.

Generally, patients with complex problems and considerable medical expenses receive case management support. Problems may be one or a combination of medical, social, financial or mental health.

Who is Eligible for Case Management?

TRICARE Prime patients (Participation is voluntary)

Who is a candidate for case management?

Any of the following diseases/diagnoses may need case management.

• Chronic or terminal illness (i.e. cancer, COPD, complex diabetes)
• Bone marrow transplants
• Non-compliance/resistance to treatment
• Catastrophic illness or injury (i.e. head trauma, major burns, spinal cord injury, etc.)
• Repeat hospital admissions or unexpected re-admissions
• Dual medical & psychiatric diagnosis
• Multiple Emergency Department visits
• Extended hospitalization
• Lack of family/social support
• Newborns in the ICU

How Long Will Case Management Services Last?

Services last until your Case Management goals are reached or until you and your case manager decide they are no longer necessary and/or helpful. Case management may be resumed at a later time if needed.

Is There a Fee?

Case management is a TRICARE Prime benefit. There is no additional charge and no billing to your insurance for this service.

Your Specific Services May Be:

• Advocacy for your needs.
• Individualized care plan.
• Link to helpful community or other federal support systems.
• Liaison with discharge planners should you be admitted.
• Clarification of your medical insurance.
• Help to self-manage your situation for positive health outcomes.
• Coordination of services among your providers.
• Scheduled needed services.

How to enroll a patient to Case Management?

Your provider or nurse may refer you to case management or you can contact a case manager directly.

Who Will Be My Case Manager?

Many competent professionals provide case management. You will likely work with a nurse and/or social worker. Everyone has the same goal - to help you reach optimum health as soon as possible.

Will My Primary Care Manager (PCM) Be Informed of These Plans and Services?

Your PCM is part of the team that helps you make plans and decisions about your health goals. Based on these goals, your case manager develops a plan and continually updates it as you progress. The PCM and you have the final say about your care.

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.

The Role of the Inpatient Case Manager [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 that will allow patients to smoothly transition to the next level of care while keeping costs to the patient at a minimum.

**DISCHARGE PLANNERS DO NOT MAKE DIAGNOSIS 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

Inpatient Case Management/Discharge Planning Services

Your Provider, the leader of your health care team, works closely with your Discharge Planner to ensure that patients move onto another level of care whether it is:

• Home care
• Out-patient care
• Alternate acute care
• Long term acute care or Rehabilitation care
• Nursing home care

Discharge Planners are available in the following inpatient areas:

• Intensive Care Unit (ICU)
• Newborn ICU
• Pediatrics
• Medicine and Surgery
• Psychiatry

Along the Way, We Share With You:

• Your progression according to the case management plan.
• Our professional evaluation of family dynamics affecting response to treatment.
• Medical insurance coverage as it impacts identified medical needs.

Your Rights:

• Be cared for with courtesy and respect.
• Be told about your health care problems.
• Be told how your problems are usually treated and share in the planning.
• Be told what you can expect from treatment.
• Agree to your treatment.
• Refuse any part of your treatment.
• Be counseled about what complications could occur if you refuse a treatment.
• Privacy.
• Be discharged from the case management program at any time you wish.

Your Responsibilities:

• Treat the case manager with courtesy and respect.
• Ask questions about any part of the care you do not understand.
• Discuss with the case manager any changes in your condition or how you feel.
• Talk to the case manager about other health problems you have had in the past.
• Inform the case manager about all medications and remedies you are using.
• Follow through on shared goals.
• Let the case manager know if you are having problems following any instructions.
• Let the case manager know if you decide not to follow the plan of care.