What Role do Case Managers Play in Patient Care?

Case managers are essential in today’s healthcare climate where improving patient outcomes, reducing readmissions and weighing the necessity of medical treatment are critical for effective care.

Brooks Rehabilitation employs Case Managers in many areas of our organization: our Inpatient facilities, Home Health, Skilled Nursing and even our Outpatient divisions within our Behavioral Medicine services.

In honor of National Case Management Week, we asked our longest tenured and shortest tenured Brooks Case Managers Shari Goranson and Christina McCullough to share the impact of the work they do and their role within the care team.

How would you describe to the average person what a case manager does?

SG: Case Managers coordinate the discharge plan and services with the patient, their family and the rehabilitation team to ensure that a patient has an appropriate care plan and services when they are discharged. We work with patients and families to educate them on their options within their available benefits.

Why is the role of a case manager important in patient care and recovery?

CM: A case manager ensures that the patient will continue to receive necessary services once they leave Brooks in order to continue their progress. The case manager helps facilitate communication between clinical staff, loved ones and community agencies to ensure continuity of care and address any questions/concerns. We work closely with the doctors, therapists and nurses to make sure the follow-up services will be appropriate for each patient.

What does a typical day look like?

SG: There are no typical days! On any given day, we can be in interdisciplinary meetings for several hours with patients and families to discuss their rehab goals. After these meetings, the outcome and discussion is sent to third party payors to make determinations that patients are at the appropriate level of care. In the interim, we are looking for services and resources for our patients that they will need at discharge. We do a lot of networking and relationship building in the areas where our patients our going home to and that includes a large geographic area. We spend time educating staff, patients and families about options specific to care.

When does a case manager get involved with patient care?

CM: Every patient in Brooks Rehabilitation Hospital has a case manager. We begin working with them the day they are admitted to our facility. Our goal at Brooks is to help patients achieve their highest level of recovery and participation in life.  Our focus is always on helping them get home.  That is why we begin planning for discharge the very first time we meet. We know that being in a rehab hospital is only a start in their recovery and we try to help patients and families understand what their long-term needs may be and help them prepare.

What is most misunderstood about case management and/or being a case manager?

SG:   There is a joke that case managers have magic wands and fairy dust that help us put together plans for our patients.  While we spend time talking with patients, families and the care team, we spend even more time behind the scenes negotiating for services that patients will need when they are discharged back into the community. I don’t think that everyone understands the amount of work that takes. Sometimes, there are no ideal answers to a problem, and speaking for myself and I think my co-workers, that hurts to the core.

What is your best case management moment?

CM: Working in the Spinal Cord Injury Unit, I see a lot of my patients make incredible progress during their stay. I love seeing them reach, and sometimes even surpass, their goals.

SG: It is very difficult to pick just one. I have been here for 22 years and have seen a lot of miracles. There are many patients and families that stand out in my mind. I love when patients and families come back to visit after they have left and continued their recovery. The best may be a letter I received from a family member “the hope began there in your office”. That patient had suffered a severe brain injury, gone thru the Brooks system of care and went on to pursue his career in film production.