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
The case manager is a valuable
resource to help you get the health services and benefits you need to make
the best recovery possible.
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
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 providing
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 quickly.
Evaluate your progress to
Will work with your
physician to ensure that your treatment is going as expected.
Which patients can benefit
from case management?
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.
Some factors indicating a need for a Nurse Case Manager include:
Complex or multiple injuries, or the patient is hospitalized.
is unclear or requires coordination
injury may permanently prevent return to the pre-injury work
The patient has
pre-existing medical conditions that may complicate or
assistance in accessing health care resources
psychological stress may interfere with recovery