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Can Case Managers Make Your Life Easier?
By Miki Fairley  In today's fragmented healthcare environment, a case manager can play a pivotal role—one that affects you, the orthotist/prosthetist. But what exactly is the role of a case manager? For whom does a case manager work? How can you work effectively with a case manager for optimal patient outcomes and fair reimbursement?
In a presentation during a Hanger Prosthetics & Orthotics Education Fair
in Reno, Nevada, Susan Rogers, RN, BSN, CCM, answered these questions. Rogers is a former president of the Case Management Society of America (CMSA) and president of Rogers Professional Guidance, Overland Park, Kansas. She also is a physical rehabilitation nurse case manager for HealthSouth Outpatient Division.
What is Case Management?
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Rogers |
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According to CMSA, "Case management is a 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."
Case managers work to connect the healthcare system and the patient together. They coordinate healthcare delivery, working with the financial drivers of payers and available resources. However, Rogers notes that case managers are not "claims police."
Case managers, including the approximately 10,000 members of CMSA, are healthcare professionals from several disciplines, predominantly nursing, and are found in many different settings. They may be independent practitioners or employed by private case management companies, payers, medical centers and hospitals, public school systems, correctional facilities, employer-based services, behavioral health programs, or substance abuse facilities, among others.
Case managers have the complex task of bringing together and coordinating all the pieces of the healthcare puzzle. According to Rogers, the role of a case manager is to be "the glue that holds the system together by producing the most appropriate patient-centered plan, coordinating the expertise and support of other professionals, family members, agencies, and providers while communicating, collaborating, and advocating for the appropriate outcome."
How does a case manager do this? According to the CMSA Standards of Practice, a case manager's functions include assessment, planning, facilitating, and advocating.
Of course in the real world, with all the cost and reimbursement issues and available resources for an individual client, the ideal solution may not always be reached, but dedicated case managers—who themselves generally come out of one of the healthcare professions—can go a long way toward making it happen.
That being said, how can you, as an orthotist/prosthetist, work effectively with a case manager for optimal patient outcomes and fair reimbursement?
Rogers outlines the following characteristics she attributes to a good prosthetist relative to the patient:
- Collaborative.
- Understands the patient's function and job.
- Understands ADL.
- Takes the necessary time with the patient—not in a hurry.
- Assists with all aspects of amputee care.
Building Relationships
Prosthetists should build relationships with the case managers over a period of time through exhibiting services and devices and supporting professional and educational opportunities, always being a resource for case managers, and being able to provide "one-stop shopping" for their patients' needs. Rogers says prosthetists and orthotists can help case managers put the pieces of the puzzle together by:
- assisting the case manager;
- being the resource; and
- being the advocate.
Rogers cites a case study of a transtibial amputee patient. The prosthetist visit was conducted before that of the physiatrist. The case manager asked for the prosthetist's input and assessment. The prosthetist established a vital comfort zone of trust for both the patient and the case manager. Rogers notes that a prosthetist must be both confident and collaborative in working with other members of the healthcare team, the case manager, the patient, and family.
In this case study, the outcome was successful in every way. Value—considered as cost/outcome—was obtained. The patient received a functional leg that enabled the patient to return to work, and the payer was satisfied with the cost and results.
"We have written up savings for many years [through case management]," Rogers says. Using the case study above as an example, Rogers notes that this patient had wanted a prosthesis found on the Internet. "When consulting with a prosthetist, Rogers and the patient learned that this [prosthesis] would not be appropriate as the patient worked on uneven surfaces. Yes, the cost was saved by using an appropriate professional, but both the case manager and the prosthetist also advocated for the patient by considering the individual's needs and lifestyle."
Important to Each Other
Prosthetists and orthotists are important to case managers. They value you as a resource for information about new products, current clinical/research updates, plus other valuable information impacting patient care. They want to develop a good relationship with you so they will know whom to call for help and what to expect, and so they can be comfortable recommending you to others.
Why should you care about case managers? Simply put, they can make your professional life easier and better by driving business to you, advocating for your patients, facilitating payments and authorizations, and coordinating all activities and communication with other healthcare team members. 
Table Of Contents - April 2007
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