Health Services

Case Management

Why Would I Need Case Management?

Case management can help by:
• Coordinating your care.
• Assessing, planning, and facilitating services for you.
• Evaluating your options.
• Advocating on your behalf.

You or your family member may need case management if you have:
• Instability with chronic health problems
• A serious terminal illness
• An increased need for different provider specialties due to multiple diseases or conditions
• A need for more support and education during a critical period

Who are Case Managers?

Case managers are usually nurses or social workers who can help you and your family figure out complex health care and support systems. They will work with you to coordinate the services and other community resources you need

They can help:
• Provide advocacy, support, and education
• Reduce burden and streamline appropriate utilization of care
• Partner with members of your healthcare team to assist in coordination of your healthcare needs
• Monitoring for progress and desired outcomes

What is Case Management?

The following guidelines will ensure prompt, effective support to meet your medical needs

Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost effective outcomes. - Case Management Society of America, 2016.

A Case Manager is your team coach. Together, you develop a plan to promptly control your illness, injury, or situation and to navigate through the maze of medical care to your recovery goal.

Generally, patients with complex problems and considerable medical expenses receive case management support. Problems may be one or a combination of medical, social, financial or mental health.   

Who is a candidate for case management?

Patients who are admitted to NH Rota and whose conditions qualify for Case Management. These conditions may be of a medical, social, financial, or mental health nature.

Any of the following diseases/diagnoses may need case management/ care coordination services.

  • Admission or transition to a post-acute facility or another treatment facility.

  • Chronic, complex, or terminal conditions (i.e. cancer, COPD, complex diabetes)

  • Catastrophic or life-altering conditions (i.e. head trauma, major burns, spinal cord injury, etc.)

  • Concerns regarding self-management or ability to comply with medical recommendations 

  • History of abuse or neglect 

  • History of mental illness, substance use, suicide risk, or crisis intervention 

  • Financial hardships, housing and transportation needs 

  • Multiple admissions, readmissions and emergency department (ED) visits 

  • Multiple providers delivering care and/or no primary care provider 

  • Polypharmacy and medication adherence needs/ Inaduaquate resources to manage anticipated or prescribed medication /treatments 

  • Previous home health and durable medical equipment usage or medical equipment needs 

  • Lack of adequate family / social or emotional support 

  • Newborns in the ICU 

How Long Will Case Management Services Last?

Services last until your Case Management goals are reached or until you and your case manager decide they are no longer necessary and/or helpful. Case management may be resumed at a later time if needed.  

Your Specific Services May Be:

  • Advocacy for your needs and your family.

  • Development of individualized care plan.

  • Link to helpful community or other support systems.

  • Discharge planning should you be admitted.

  • Clarification of your medical insurance.

  • Help to self-manage your situation for positive health outcomes.

  • Coordination of services among your providers.

  • Scheduled needed services.  

How to enroll a patient to Case Management?

Your provider or nurse may refer you to case management or you can contact a case manager directly.   

Who Will Be My Case Manager?

Many competent professionals provide case management. You will likely work with a nurse and/or social worker. Everyone has the same goal - to help you reach optimum health as soon as possible.  

Will My Primary Care Manager (PCM) Be Informed of These Plans and Services?  

Your PCM is part of the team that helps you make plans and decisions about your health goals. Based on these goals, your case manager develops a plan and continually updates it as you progress. The PCM and you have the final say about your care.

Your Rights:

  • Be cared for with courtesy and respect.

  • Be told about your health care problems.

  • Be told how your problems are usually treated and share in the planning.

  • Be told what you can expect from treatment.

  • Agree to your treatment.

  • Refuse any part of your treatment.

  • Be counseled about what complications could occur if you refuse a treatment.

  • Privacy.

  • Be discharged from the case management program at any time you wish. 

Your Responsibilities:

  • Treat the case manager with courtesy and respect. 

  • Actively participate in your wellness and care.  

  • Ask questions about any part of the care you do not understand. 

  • Discuss with the case manager any changes in your condition or how you feel. 

  • Talk to the case manager about other health problems you have had in the past. 

  • Inform the case manager about all medications and remedies you are using. 

  • Follow through on shared goals. 

  • Let the case manager know if you are having problems following any instructions. 

  • Let the case manager know if you decide not to follow the plan of care.

Contact Us

Location:

Room E-230 (MSW)

Desk Phones:

Comm:

(011) 34-956-82-3680
(011) 34-956-82-1593

DSN:

(314) 727-3680
(314) 727-1593

From Base:

727-3680
727-1593

Hours of Operations:

Monday through Friday: 0730-1530
Weekends: Closed

Don't forget to keep your family's information up-to-date in DEERS.