What is Case Management?
Case Management is the satisfying job of helping people live their best life possible by identifying their unmet healthcare needs and providing all available resources to help meet those needs by tying together the fragmented bits and pieces of health information patients are working with into a unified whole.
Per Deanna Cooper Gillingham’s book, CCM Certification Made Easy, The American Case Management Association, or ACMA, defines case management as a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client’s health and human services needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes (page 2, italics mine).
That definition and those elements are important, but the real joy in case management, for me, comes in helping people, one individual at a time, achieve better health through finding out exactly what they need, what’s keeping them from getting that, and helping them get integrated care to help them live their lives as freely and happily as possible. Individual patient stories demonstrate how these principles are put into action! As a telephonic case manager for an insurance company, I would like to share a member story that demonstrates some of these principles and actions.
One day, I called a member, we’ll call her Michelle, who had poorly managed diabetes and had suffered a stroke which resulted in speech difficulties. Michelle lived alone, but her daughter was available to help her with her healthcare. Her daughter, we’ll call her Amy, said “Mom wants to manage her diabetes better, and I know that checking her sugars is important, but with her fixed income she just cannot afford to buy a machine, never mind everything else, like those strips and the needles. I know diet is important, too, but it’s just so hard to eat healthy food, and it’s so expensive! And she really doesn’t know what to eat. Plus, she can hardly talk right anymore. I’ve called her doctor a few times, and she’s getting home health, but for some reason, they still haven’t sent out a speech therapist. We just don’t know what to do.” Amy agreed to work with the Case Manager to find her what her mother would need to best manage her conditions, but sounded doubtful that the case manager would be able to help. Sometimes, despite our best efforts as case managers, we are not able to help and that’s disappointing. But I am always determined to do everything possible to help these members get the care they need.
Here are the action steps I took to get the member she needed and was entitled to.
Planning: My plan included finding resources for Michelle to obtain diabetic testing supplies for free and arrange for this member to get home speech therapy. Also, we discussed some ways to improve her diet on that phone call, and Michelle and Amy were able to determine some simple changes that the member could start on right away, such as drinking Diet Coke instead of regular Coke, eating more vegetables, and substituting a light evening snack such as cheese and crackers, rather than pie or ice cream for dessert before bedtime. I also offered a Social Work Consult to address the issue of difficulty affording nutritious food, which she accepted. Michelle was able to take some concrete measures to improve her diabetic management right away, after just one phone call, and was referred to Social Services.
Luckily, in this case, success with obtaining diabetic supplies was quick. To facilitate the goal of getting the member a glucometer, strips, and lancets, I called this member’s pharmacy and determined that she qualified to get free diabetic testing supplies. Resource management was achieved by providing needed diabetic supplies that were already covered by her insurance – she just didn’t know how to access this. This was an easy and cost-effective solution to this problem.
Care coordination: Care coordination involved speaking with this Michelle’s physician’s office to make sure the diabetic supply order was sent to the pharmacy in a timely manner, then following up with the pharmacy to make sure they had received the order.
Advocacy: I advocated for Michelle by being persistent with calling her MD office until home Speech Therapy was ordered and initiated.
One week later, Michelle had received her glucometer and had started Speech Therapy. Amy was still speaking on Michelle’s behalf, due to Michelle’s speech difficulty. I discussed Michelle’s results with Amy, which were very encouraging, with her blood sugar levels averaging less than 120, whereas before, her levels were frequently approaching 200. Michelle had implemented some medicine adjustments and had improved her diet as well, and was really proud that her blood sugar results reflected that. Amy said, “It’s just really nice to get some feedback about how all of this is working! And she hardly misses her Cokes at all! I haven’t seen a whole lot of improvement in my mom’s speech yet, but I can tell she’s encouraged that a therapist is working with her, and I know it will get better. Plus, the social worker called, and we have filled out an application for food assistance. I hope Mom qualifies!” It made me so happy to hear the change in her voice, which was dull and discouraged on our first call, full of hope and optimism on our second call.
My Case Management efforts helped Michelle make concrete improvements in her health, and while they are not terribly dramatic, they will make a huge impact in her life, and that’s one aspect of why Case Management is such satisfying work. There will be some dramatic cases, but most of them are more subtle – the patients that I help generally don’t need emergency surgery right then, but they sure need help, guidance, and resources, which Case Managers are uniquely qualified to assist with. Helping one patient at a time, in both small and large ways, adds up to a career spent helping hundreds of people over time, and that is very satisfying indeed. I love this career!
Guest post from Amanda Bennett Williamson BSN, BA, RN, CCM, submitted as part of our “Case Management Is… Contest” and selected as an Honorable Mention!
Hi! Amanda Bennett Williamson from New Orleans, LA. I recently got married! I’ve been working in healthcare for over 20 years. I love yoga and Mardi Gras..