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What is Case Management?

Medical case management is a collaborative process that facilitates recommended treatment plans to assure the appropriate medical care is provided to disabled, ill or injured individuals.

It refers to the planning and coordination of health care services appropriate to achieve the goal of medical rehabilitation. Medical case management may include, but is not limited to, care assessment, including personal interview with the injured employee, and assistance in developing, implementing and coordinating a medical care plan with healthcare providers, as well as the employee and his/her family and evaluation of treatment results.

Medical case management requires the evaluation of a medical condition, developing and implementing a plan of care, coordinating medical resources, communicated healthcare needs to the individual, monitors an individual’s progress and promotes cost-effective care.

Certified Case Manager

The Certified Case Manager (CCM) credential is available to health care providers licensed to practice independently in the American health care system. For example, the license would be available to Registered Nurses but not to Licensed Practical Nurses, who are not licensed to assess and evaluate the health of their clients.

Because holistic training is the basis for the Registered Nurse, Social Work, Occupational therapy and most all degree programs in the health sciences, the transition into case management is a natural progression of skill.

Case management focuses on delivering personalized services to patients to improve their care, and involves four steps:

1) Referral of new patients (perhaps from another service if the client has relocated to a new area out of previous jurisdiction, or if client no longer meets the target of previous service, such as requiring a greater level of care. Alternatively, they may be referred after having been placed on an ITO or in an inpatient unit.

2) Planning & delivery of care

3) Evaluation of results for each patient & adjustment of the care plan

4) Evaluation of overall program effectiveness & adjustment of the program.

In the context of a health insurer or health plan it is defined as:

A method of managing the provision of health care to members with high-cost medical conditions. The goal is to coordinate the care so as to both improve continuity and quality of care and lower costs.

Specific types of case management programs include catastrophic or large claim management programs, maternity case management programs, and transitional care management programs.


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