Goals of case management: The principal goal of case management is to help patients and their families navigate the complex and fragmented health care system by coordinating efforts among service providers to deliver timely, appropriate, and cost-effective care according to each individual’s needs. Health care has been increasingly moving toward a patient-centered model, in which the values, preferences, cultural traditions, family situations, and lifestyles of patients and their families are taken into consideration. Therefore, case management typically tries to involve patients and their families in prevention plans, treatment options, and financial decisions. It also aims to reduce health care costs for patients and service providers. By coordinating all the various functions of treating people for serious diseases such as cancer, efficiency is increased and cost is decreased. Case management also tries to improve the standards of care for patients.
Many medical and government organizations along with individual hospitals, clinics, and medical centers (including cancer centers) have established case management guidelines. These guidelines, based on empirical research and numerous trials and observations, provide a system to help patients across what is known as the continuum of care. Clinical and ethical standards apply in all areas of care, from prevention of disease to end-of-life issues, and to all the components of case management.
Case management components: Case management has developed a set of core components: screening and assessment, treatment, community involvement, arranging for nonmedical services, monitoring, and reassessment. These core components, along with sets of subcomponents, come together to create a specific care plan for each patient. For example, the case management components and subcomponents for the care plan of a seventy-five-year-old man with prostate cancer might include the following:
- Screening and assessment: examinations by the patient’s primary care provider, referrals to an oncologist or urologist, testing to determine the nature of the disease, establishing a treatment plan based on the stage of the cancer, evaluating the patient’s financial status, creating the cancer care plan
- Treatment: aggressive radiation therapy, five days a week for seven weeks at a cancer center
- Community involvement: scheduling rides for the patient to and from the cancer center with volunteers from the local chapter of the American Cancer Society, introducing the patient and the patient’s family to a local support group, referring the patient to an oncology social worker
- Arranging for nonmedical services: working with Medicare or Medicaid to pay for treatment
- Monitoring: periodic checking to see that all components of the cancer care plan are functioning, and adjusting the plan if necessary
- Reassessment: scheduled follow-up visits with doctors, the oncology social worker, and Medicare or Medicaid
Managing all these components to create the cancer care plan is the job of the medical case manager.
The medical case manager: Most medical case managers (MCMs) are registered nurses. The medical case manager may also be a staff member of a hospital or cancer center and is often hired by an employer or insurance carrier. The role of the medical case manager includes, but is not limited to, the following:
- Overseeing patients’ cancer care throughout diagnosis, treatment, and follow-up
- Assessing patients’ health, nutrition, psychological, and care needs
- Assessing patients’ financial needs
- Educating patients on different cancer types, treatments and side effects, and possible outcomes to allow them to make informed decisions about their care
- Helping patients communicate more effectively with their doctors
- Linking patients with the appropriate community resources
- Coordinating the efforts of the cancer care team
The cancer care team: Each cancer patient’s needs are different. Meeting those needs requires a team of professionals with different expertise. Depending on the patient, the cancer care team may consist of the following individuals, all under the watchful eye of the medical case manager:
- Oncology social worker: a professional trained in counseling and providing practical assistance in navigating the health care system
- Psychiatrist or psychologist: to help the patient who has trouble coping psychologically with cancer
- Nurses: providers of a wide range of help, from implementing the care plan to answering questions for the patient and family
- Home health aide: a worker who helps cancer patients at home with daily living tasks
- Rehabilitation specialists: physical, occupational, and speech therapists who help patients recover from the physical changes caused by cancer or cancer treatment
- Oncology nutritionist: a specialist who advises on diet to help the patient cope with the consequences of cancer and side effects of treatment
- Hospice workers: caregivers who focus on the special needs of patients with terminal cancer
Case management
Cohen, E., and T. Cesta. Nursing Case Management: From Concept to Evaluation. 3d ed. St. Louis: Mosby, 2000.
Fattoursso, D., and C. Quinn. A Case Manager’s Study Guide. 2d ed. Sudbury, Mass.: Jones and Bartlett, 2004.
Mullahy, C. The Case Manager’s Handbook. Sudbury, Mass.: Jones and Bartlett, 2004.
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