Each day, clients tell about having to deal with
insurance networks and the time and frustration involved. Your insurance network will probably assign a case manager to you in time, but you can get
an early start by requesting a case manager.
The case manager is a valuable resource
to help you get the health services and benefits you need to make the best
In cases where a patient has long term treatment that complicate the
process, the case manager (CM) will act as your advocate and advisor,
assisting your progress through a complex healthcare and benefit system.
"Long term" can mean a month or more (i.e. chemotherapy, radiation, or
chronic disorders, including alopecia or trichotillomania). The
CM will be your main contact at the with the insurance company.
Case managers do not make diagnoses or
treatment decisions, nor do they make judgments about your eligibility for
benefits. Their role is to facilitate access to timely and appropriate
healthcare services, and to ensure continuity throughout the recovery
Patients often find it challenging to
understand and access the care and benefits they need. The CM can help you
by acting as your advisor, an advocate, and a mentor throughout recovery and
return to normal. The CM will:
- Help you understand the goals and expected outcomes of treatments,
services, and benefits:
- Identify overall needs for recovery by assessing your diagnosis, history,
treatment protocol, and progress to date. This will involve gathering
information and recommendations from you and other healthcare professionals
- Ensure continuity of care by acting as liaison between various health
professionals and services;
- Act as patient advocate by helping adjudicators and other parties
understand your health care situation and health care needs
- Coordinate care and services so that you can access them easily and
- Evaluate your progress to recovery
- Will work with your physician to ensure that
your treatment is going as expected.
patients can benefit from case management?
Some factors indicating a need for a Nurse
Case Manager include:
In general, any patient who faces challenges regarding care and recovery
is a candidate for case management. This includes (but not limited to)
patients who are hospitalized, those who require care from multiple health
professionals or services, and patients who have personal or psychological
circumstances that may interfere with recovery.
Complex or multiple injuries, or the patient is hospitalized.
- Treatment plan
is unclear or requires coordination
- Patient's injury may permanently prevent
return to the pre-injury work
- The patient has pre-existing medical
conditions that may complicate or prolong recovery
- Patient needs assistance in accessing
health care resources
- Emotional or psychological stress may
interfere with recovery