By Annette Watson

They might be called case managers, care coordinators, or discharge planners. Whatever their title, their responsibility is to help you navigate a virtual sea of options and services -- especially helpful guidance if your care needs are chronic or complex.

Typically, a case manager might be recommended or assigned to you if you are in an inpatient setting in a hospital or a skilled nursing or other long-term care facility.

Many people entering a rehabilitation situation do not know what a case manager is and what benefits case management can provide. Mabel Floreza and Jennifer Avian, RN case managers for the California Pacific Regional Rehabilitation Center in San Francisco, describe case management as the hub of patient care: "We act as the voice for the client. We provide continuity, advocacy, and cohesiveness. We want patients to understand their own health status and what they can do about it. We educate, make resources available, and provide lines of communication between the patient, their families, physicians and other professionals, and payers. Case management provides benefits to everyone involved."

What to ask a case manager

Your relationship with a case manager is a two-way communication. Floreza adds, "When matching your needs to a case manager's expertise, you need to look for someone who is a good communicator, knowledgeable of the resources, and not afraid to go to bat for you. Find someone that you are comfortable talking and working with."

A case manager will suggest options and opportunities for your care -- but acceptance of the case manager's suggestions is up to you, as is use of the case manager at all. One of the first questions in your exchange with a case manager will likely come from him or her:

"Do you consent for me to help coordinate your services?"

A case manager should never be imposed on you against your will -- and a service provider should not deny you care if you choose not to use a particular case manager. Exceptions to this principle may occur when Workers Compensation is a factor or when a case manager is assigned to you by a government agency or court of law.

Rhoe Saporito, RN case manager at the Patricia Neal Rehabilitation Center in Knoxville, Tennessee, says, "Allowing us to coordinate services permits flexibility in developing the discharge plan. We have resources that many patients do not know about. For example, we have many resources to assist patients with getting their medications at discharge, such as low-cost pharmacy programs, drug assistance programs from pharmaceutical companies, sample medications from physician offices and indigent care clinic's pharmacies. We also do follow-up care after the patients leave the center."

You will want to raise questions to ensure a particular case manager is the best match for your needs. The case manager needs to be able to demonstrate case management experience related to your particular condition. One of your first questions to a case manager will be:

"How can you help me with my services?"

A case manager should be able tell you what he or she can do to ensure your access to care and services. For example, the case manager's role is not limited to arranging your necessary doctor's appointments; it also includes ensuring you have transportation so you can keep the appointments.

Kathy Durham, RN case manager at Lawnwood Physical Rehabilitation Center in Fort Pierce, Florida, describes how she evaluates the needs of her clients: "I look at how I can make a system of supports for a person to have a safe discharge to their home. I look at their history, level of function, living arrangements, and more. I can obtain medical equipment for them, arrange transportation, work with community service providers, and even touch base with their financial issues to make sure their plan is affordable to their means. I ask about their goals and expectations and find resources that are suitable to meet those goals."

It is also important to understand who pays for the case manager's services. Perhaps the second question to pose to the case manager who has been recommended or assigned to you is:

"Who do you work for?"

The answer you want to hear, of course, is, "I work for you!" Indeed, a case manager should be your advocate for access to care, and if services are not covered by your insurance or government program, he or she should be willing to seek alternative sources of funding.

For example, if a case manager is helping you transition from a care facility back to your home, you might need help preparing your meals. Even if this service is not covered, a case manager should have a contact who can arrange home delivery of your meals. And, if meal delivery will be a financial burden for you, the case manager should know of resources to partially or fully pay for your service.

So who writes the case manager's paycheck? It might be the hospital or facility where you are receiving services. It might be your insurance company, governmental agency (such as Medicare or Medicaid), or another third-party funder of services. Geriatric care management, however, is usually not covered by public or commercial health insurance programs, but is paid for by the consumers themselves or their families. Some nonprofit agencies might partially pay for case management or charge for the service on a sliding scale, based on your income.

Why is it important for you to know who pays for the case manager's services? If you have a complaint about your services, you will want to be aware of any potential conflict of interest. During the course of your care, you should always have access to a complaint and appeals process if you are dissatisfied with the services. For example, if a case manager's salary is paid by a hospital and you lodge a complaint with your case manager about the hospital's services, it might present an ethical dilemma to the case manager: should he or she advocate for the employer or for you, the consumer?

A case manager's primary commitment should be to you. She or he should act on your behalf!

You should be wary of a case manager who insists your services will not be covered unless you work with him or her. Which leads to another question you might pose to your case manager:

"Are you a certified case manager?"

Case managers who have earned their certification are bound by a code of ethics to arrange for optimum care on your behalf.

Certification is a sign of integrity, competency

Certification is a step beyond an educational degree, such as those held by a social worker or nurse. To earn certification in a particular area of practice, an individual has to meet a certifying body's set of criteria regarding education, knowledge, and experience.

In the United States, several organizations provide certification to individual case managers. The largest is the Commission for Case Manager Certification (CCMC), which has certified approximately 30,000 case managers since 1990. Health and human service professionals who are certified by the CCMC conform to standards of practice that are periodically reviewed and updated by the Case Management Society of America (CMSA) to ensure their relevancy and value.

Counting more than 10,000 members, CMSA is the largest professional membership organization for case managers. CMSA has also recommended a Case Management Model Act to help public policymakers write legislation to promote and protect case management that can lead to higher consumer satisfaction.

If you believe a CCMC-certified case manager has not followed the professional code of conduct, you can lodge a complaint through the CCMC. Although complaints are rare, they are taken seriously by CCMC and reviewed by the commission's ethics committee. You may have little recourse, however, if your case manager is not CCMC-certified because not all certifications have this important consumer protection.

Care coordination a growing trend

As a consumer, you might have one more question to ask:

"Are the benefits of case management proven?"

Several studies have demonstrated that a coordinated care approach results in lower hospital readmission rates. One such study, conducted by Johns Hopkins University professor Gerald Anderson, is highlighted on the U.S. Department of Health and Human Services' Substance Abuse & Mental Health Services Administration website.

Many primary care practices are transforming into what is known as a "Medical Home." In a Medical Home, a patient's care among a number of specialists is coordinated in a central location, resulting in improved communication among physicians and professionals from other disciplines who provide your care. A case manager will be an important part of the Medical Home model.

When you are faced with a vast and sometimes mystifying sea of possibilities, a good case manager can be a helpful navigator, steering you toward higher quality services and more efficient care. If a case manager is not offered, ask if one is available for you and then ask the other questions in this article to ensure your case manager is working for you.

About the author:

Annette Watson, RN-BC, CCM, M.B.A., is managing director for global emerging business at CARF International, www.carf.org, an independent accreditor of health and human services, including service providers that offer case management. She is chair elect of the Commission for Case Management Certification and member of the Case Management Society of America.