Case Management

Definition of Case Management
Case management is the collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes.

Philosophy of Case Management
Case management is not a profession in itself, but an area of practice within one's profession. The premise is that when an individual reaches the optimum level of wellness and functional capability, everyone benefits: the patient, their support systems, their employer, the health care system and the various reimbursement sources.

Case management serves as a means for achieving wellness through advocacy, communication, education, identification of service resources and service facilitation. The case manager helps identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source. Case management services are best offered in a climate that allows direct communication between the case manager, the client, and appropriate service personnel, in order to optimize the outcome for all concerned.

Certification determines that the case manager possesses the education, skills and experience required to render appropriate services based on sound principles of practice.

Reasons For Referral

• To obtain definitive diagnosis
• Causal relationship of treatment is undetermined
• Illusion of sufficient medical care without resolution
• Long standing pre-existing conditions prolonging disability
• Complicated diagnoses; diagnosis/prognosis without progress
• Two or more conditions related or unrelated to the work injury
• Claimants seeing several physicians or frequent emergency room visits
• Need for medical reports and coordination of services for timely conclusion
• To establish causal relationship between a work injury and current condition
• Prolonged conditions that may or may not need surgery
• No medical reports
• Conflicting reports and/or extended disability without apparent medical cause
• Prolonged medical care when the injured worker is able to return to work
• Documentation insufficient to return claimants to work or support disability
• Jobs which are inappropriate to sustain attendance at work
• Return to work difficulties because of unresolved medical conditions
• To prevent employer and employee misunderstandings regarding return to work
• Employment with a new company as disability continues
• Claimants suspected of working while on workers' compensation disability