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What Is Medical Case Management?

By Florence J. Tipton
Updated May 17, 2024
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Medical case management is the process of supervising a medical condition from diagnosis to recovery through the use of an individualized treatment plan. Typically, case managers are responsible for coordinating all aspects of the treatment plan with medical professionals and the patient. An evaluation of the patient’s condition typically guides decision-making throughout the medical case management process. By monitoring progress during treatment, medical professionals can determine whether revisions are necessary to influence the expected outcome. Case managers also navigate communication channels between the patient and medical professionals to ensure a continuum of care occurs.

The first stage in the medical case management process is usually an evaluation of the patient’s condition. At this point, a medical professional — either a physician or medical specialist — may perform examinations and tests to make an accurate diagnosis. Making the proper diagnosis during the evaluation helps to establish appropriate treatment for a full recovery.

Based on evaluation results, the next stage might include the coordination of resources needed for the treatment process. The focus for executing the individualized treatment plan is on linking medical care and available resources. One primary resource typically includes determining the medical care providers who will treat the patient. Other resources normally include funding for treatment and purchasing rehabilitation equipment.

Following the evaluation stage in medical case management is the selection of and collaboration among medical care providers. For example, a neurology specialist and physical therapist is usually required if the patient suffers a brain injury after an accident. Diagnosis of a form of cancer might require treatment from staff at a medical facility and in-home care.

Equally important to the medical case management process is securing funding such as health insurance or charity programs to cover related treatment expenses. Often, the case manager is charged with determining which medical services related to treatment are covered in a health insurance plan. If insurance offers limited funding, the case manager could research alternative methods for payments such as local charity organizations.

Another aspect of medical case management is to closely monitor patient progress. Closely monitoring patient progress can alert the case manager to issues that could derail a successful recovery. Monitoring helps medical care providers continue with the initial treatment plan or make adjustments, if necessary. Part of the monitoring process might include predetermined time intervals to evaluate the success of the plan. Sometimes, monitoring also continues with periodic checkups after treatment ends.

Throughout the medical case management process, the case manager normally maintains ongoing communication between the patient and medical care providers. Meeting with the patient could offer insight about the need for other supportive services important to the plan. Regular updates from the medical care providers can also ensure the treatment is progressing accordingly.

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