Case Management

What is Medical Case Management?

The Case Management Society of America, CMSA, defines medical case management as the coordination of appropriate health and social services so that an individual can reach the highest possible level of physical and mental functioning after an injury or illness. It is a collaborative process of assessment, planning, facilitation, and advocacy for services to provide clear direction in the pursuit of medical care, thus helping an individual reach his or her rehabilitation goals.

The essential purpose of case management is to optimize the quality of life for an injured individual and for his or her family. The ultimate aim of case management services from SCM Associates, Inc. is to maximize the well-being of an individual whose life has been disrupted and sometimes permanently altered by an accident, injury, or chronic health problem.

The underlying principle of case management is to achieve the optimum level of wellness and functional capability for the patient, thereby enabling everyone to benefit: the individuals being served, their support systems, the health care providers, and the various sources of reimbursement.

Case management serves as a means for achieving client wellness and autonomy 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. Case management services are best offered in a climate that allows direct communication among the case manager, the client, and appropriate service personnel, in order to improve the outcome for all concerned.

Common Barriers to the Healing Process

  • Lack of understanding of medical terminology by the patient
  • Failure of the patient to follow medical or rehabilitation recommendations
  • Miscommunication
  • Lack of pertinent information being made available to the medical provider in a timely manner
  • Difficulty making contact with medical or rehabilitation providers outside of treatment sessions
  • Lack of coordinated care among medical or rehabilitation providers
  • Differences of opinion between the patient and the medical or rehabilitation provider
  • Feelings of frustration in the patient
  • Lack of care coordination between stages of care

SCM provides case management services to payors of healthcare, as well as to trust funds, individuals, employers, and other case management organizations. We strongly believe that improved patient care will reduce the costs to all parties involved. A coordinated healthcare plan helps to alleviate wasted time and resources, as well as establishing an effective plan of action.

Health Insurance Providers

The rising costs of healthcare have triggered a more in-depth analysis of how claims are processed and the cost allowed for services to members. This is especially true for the costs associated with catastrophic cases that disproportionately consume funds.  One way healthcare companies have tried to find a balance to these rising costs is the utilization of case managers as intermediaries who can coordinate multiple service providers and ensure that the patient is getting the care they need to reach their optimal level of recovery in a timely manner.

Examples of common cases where healthcare companies would require case management assistance are catastrophic or large claim management programs, maternity case management programs, and transitional care management programs. By identifying patients with potentially catastrophic illnesses, contacting them and actively coordinating their care, plans can reduce expenses and improve the medical care their participants receive.

Private Companies and Employers

Employers face multiple problems associated with employee absenteeism and managing the effects of lost productivity.  Proactive intervention is sometimes needed to facilitate an employee’s recovery and timely return to work. Many employers are beginning to engage the services provided by nurse case managers in their Return-to-Work programs, aimed at accomplishing these goals in order to achieve more positive medical outcomes, minimize litigation, and increase, or at the very least leverage, productivity concerns.

By providing health education, following up on work absences due to poor health or chronic illness, and verifying reasons for employee absenteeism employers hope to reduce the costs incurred from employees missing work, and they are better able to plan for those who need to take extended leaves of absence.

Workers’ Compensation Carriers

In instances that involve worker’s compensation carriers, case managers coordinate the physical rehabilitation of a worker injured on the job. Using case management services can help to effectively facilitate medically necessary services and to promote optimal patient outcomes. This approach can reduce the period of disability, and assure a high quality of care at an appropriate cost.

Community-Based Organizations

The shortage of government- and community-funded programs has increased the need for case managers to establish client linkages to reimbursement programs and to increase access to medical, social, or vocational agencies in order to resolve issues of medical care, housing and employment. Case managers in these programs are usually particularly skilled at meeting the social needs of patients, providing transportation, and assuring that clients keep their appointments at the various agencies are important components of their activities. This type of case management is probably the most established of all, and it has provided the foundation for other care providers to adopt its techniques.

We follow the standards of practice for Case Management as produced by the Case Management Society of America, CMSA.

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

The Commission for Case Management Certification, CCMC, developed a scope of practice for Case Managers as a representation of professional opinions regarding what constitutes appropriate delivery of effective case management services. It is considered unethical for case managers to operate outside of their individual scope of practice limits.

The experience SCM has gained from being in the case management industry for more than 20 years affords us the expertise needed to attain the outcomes our clients and patients want and need.  We attribute this success to:

  • The quality and professionalism of our staff
  • Our staff’s high level of experience
  • Flexibility of our services
  • Our focus on quality of care
  • Commitment to quality of care