What You Need to Know About the 4 Levels of Medical Case Management

By June 29, 2020 No Comments
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What is Case Management? According to the Commission for Case Manager Certification, case management is defined as a “collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet a client’s health and human service needs.” Basically, case management companies focus on the client’s well being, wellness, and full functional capability.

When it comes to case management in workers’ compensation, case management specialists not only coordinate with injured workers and employers but also the clinicians who will evaluate the cause of the injured worker’s claim and develop a treatment plan. The main goal of medical case management is to ensure that the injured worker gets the right treatment at the right time so that the patient can return to work either in a full or light duty capacity.

There are 4 levels of medical case management: Intake/ Referral, Needs Assessment, Service Planning, Monitoring and Evaluation. Each level is very crucial. Case management companies need to strictly implement and fulfill each of these four levels to ensure the health of the injured worker.

Intake and Referral

The first level is the intake of the client by the case manager. Once a referral is received, the case manager is provided with all the injured worker’s information, medical records and claim documents including past and current health conditions, socio-economic and financial status, health insurance plan benefits and coverage and more.  It is very important to identify the injured worker’s immediate needs and begin to establish trust and establish a relationship during the information gathering process either over the telephone or through face-to-face contact. All medical aspects of the claim will be handled by field and telephonic nurses who are very knowledgeable about medical treatment guidelines. The first level is very important for the case management specialist so it can move on right away to the next level and expedite the whole process.

Needs Assessment

In the second level, the case manager will review the records and information collected during the intake and referral stage. The primary objective in this level is to identify an injured worker’s problems, challenges, and risks and the circumstances that led to the injury or sickness. Case managers will consider the injured worker’s co-morbidities and socioeconomic hinders for effective recovery. Within 24 hours the case manager will make the appropriate contacts with adjusters to assist in bringing about the most appropriate and cost-effective solutions for care. This ensures the injured worker to achieve medical improvement and return to work with shorter days of disability.

Case managers are professional nurses who will do everything within their ability to move claims in a positive direction. At this point, the case manager will determine the expected care goals and target outcomes.

Care Planning

 The third level is very important for the success or failure of an injured worker’s case. After establishing the specific objectives and short and long-term care goals, the case manager will develop a comprehensive plan of care that addresses the injured worker’s problems and needs. The action-oriented and time-specific plan also details the treatments and services needed to meet the needs that were identified during the Needs Assessment level.

During the development of the case management plan of care for the client or injured worker, the case manager considers all inputs and approvals of the client, their employer, and their healthcare provider. After the services and resources needed have been identified. the case manager assigns, executes, organizes, and schedules the care management activities and interventions such as tests, schedule of physician’s visits, operations and other procedures, therapy, and even post-hospital discharge such as home care services.  The case manager is also responsible for sharing ongoing information with the injured worker and their support system, the health care providers or clinicians, the health insurance company or payor, and other agencies involved in the client’s care and case management plan.

Monitoring and Follow-Up

In the last phase, the case manager will review and evaluate the effectiveness of the client’s case management plan, the effect on the client’s health condition, the knowledge of the treatment regimen, and the outcomes of the procedures and medical interventions. Reassessment will be done and modifications may be made with additional recommendations for care if needed. Another important element in this level is monitoring the injured worker from the time of discharge to transfer to either another facility or home care. Communication is very important between the case manager, the injured worker and their support system, and other members of the healthcare team. The case manager needs to educate their client about post-transition care and follow-up, assist in securing medical and disability equipment if needed, and even schedule transportation services. During the phase, case managers also need to regularly provide progress reports that include significant updates about the client’s comfort, medications intake, and any issues or concerns and changes to the care plan and return to work schedule.

To ensure the safety and well-being and positive outcomes of care that the injured worker undergoes during the medical case management process, case managers must diligently follow these procedures and proceedings for workers’ compensation. They need to maintain a primary and consistent focus on quality of care, maintain safe transition between each level of care, provide timely access to services while always focusing on the client’s needs.

As one of the premier private case management companies, Novare answers the needs of employers and the insurance community who are seeking effective and responsible medical management services for injured workers. Based on reliable science, Novare improves the outcomes for the injured worker and lowers the costs for the employer. Novare delivers personalized representation and efficient, cost-conscious services while promoting an environment that is conducive to the well-being of the injured worker. Our team of professional medical case management specialists is dedicated to meet your specific worker’s compensation managed care needs.

Let Novare handle your workers’ comp needs. Give us a call today at 866 532 2929!