||Case Management is a process of coordinating an individual's total health care services to achieve optimal, quality care delivered in a cost effective manner. The process integrates assessment, planning, implementation and evaluation components.
Based on the complexities of health care and business environments, case management services must be delivered by qualified health care professionals with sufficient knowledge and expertise to perform this important function competently. CasePro case managers provide case management at four levels: case review, telephonic case management, field case management and catastrophic case management.
Review of injured employees' file to ascertain course of illness or injury, level and quality of health services, determination of appropriateness of services, and progression of the case toward resolution. If adequate information is available to make these determinations, and the case is progressing satisfactorily, reassessment of the case takes place monthly, or until the employee reaches maximum medical improvement (MMI) and/or returns to work, but no more than 90 days. Field case management may be indicated. If inadequate information is available or if the case is not progressing satisfactorily, a direct telephonic review would be recommended.
Telephonic Case Management (TCM)
Provides telephonic communication with the injured employee, health care provider(s) and employer. The purpose is to gather more accurate and current information, disseminate information and provide input in the course of events surrounding the case.
If the case is progressing adequately, monthly review takes place until MMI is reached and/or the employee returns to work, but no more than 90 days. After that time, field case management may be indicated.
Field Case Management
Recommendation for field case management takes place when an employee is not compliant, is disgruntled with the employer, more direct observation is recommended, the case is not progressing or referral to another provider may be recommended.
Referral to field case management should be considered for claims in the following circumstances:
- File open more than 90 days
- Catastrophic injury
- Lack of objective findings to support subjective complaints
- Injury to the back, knee or shoulder
- Failure to respond to conservative treatment
- Prolonged (more than eight weeks) use of chiropractic care or excessive physical therapy including work hardening and work conditioning programs
- Referral to multiple providers with no progression toward closure
- Injured employee non-compliant with medical care
- Excessive use of narcotic and/or addicting medications
- Failure of injured worker and/or physician to cooperate with TCM
- Pre-existing condition, such as diabetes that may affect recovery
Catastrophic Case Management
Catastrophic cases are identified based on diagnosis, complexity and expected increase in cost. These cases require expert medical case management intervention by specially trained catastrophic nurses. The catastrophic case manager is an advocate for the injured/ill individual while serving as liaison between the individual, claims representative, health care providers, employer and the community. The overall goal is to maximize the individual's potential towards independence and medical stability while maintaining cost containment measures.
The "Holistic" approach is used and maintained throughout the management of the catastrophic case. This involves the gaining of rapport and confidence in cooperation with physicians, institutions, claims departments, social agencies and employers. The catastrophic case manager is the coordinator for the treatment team.
Catastrophic injuries/illnesses may include, but not limited to:
- Head injuries
- Amputation of limb(s), hand(s) or feet
- Spinal cord injuries
- Heart attacks
- Multiply fractures/crush injuries
- Mental illness
- Acquired immune deficiency syndrome (AIDS)
- Traumatic hearing loss
- Serious burns