Care management refers to the combination of services and activities that help patients with chronic conditions manage their health. The goal of care management is to improve patient health and outcomes. Some of these key outcomes include improved care coordination, reduced hospital visits, and greater patient engagement. Some health insurance plans such as Medicare Advantage plans offer care management free-of-charge to patients who would benefit. In other cases, care management is a service that can be paid for out-of-pocket by a patient or family who would like more support. Either way, the process will be similar.
Understanding the care management process can help you to know what to expect and make the most out of the care manager’s services. All patient and family situations are unique and should receive personalized care management. There are generally 3 steps in the care management process:
The first step is a comprehensive in-person assessment. Questions asked during this interview will cover medical history and current health and living situation. This will include medication names, doses, and frequencies, dietary habits, daily activities, and memory. The assessment of daily activities will cover ability to complete activities of daily living (ADLs) such as eating, bathing, toileting, and dressing. Additionally, the care manager will ask about and document your finances, insurance status, and advance directives if applicable. Many of these questions will be asked of both the patient and their family members. If family members live out of town, the care manager will typically make a phone call to ask necessary questions. All these questions give the care management team a comprehensive baseline understanding of the patient and family situation.
The second step will be your care manager creating a customized care plan. The care plan includes the results of the initial assessment as well as personalized recommendations for healthy aging. Recommendations are provided in great detail including professional and medical resources in the community that can help address need areas. The need areas covered by the initial assessment will include a broad range of issues including medical, social, nutritional, home safety and more. Lastly, the care plan will offer a recommendation for how often and to what extent the care manager will visit and offer support.
The third step will be the care manager making arrangements for needed services. Care managers are experts in local community services for older patients and their families. In some instances, a care manager will also start to attend important doctor’s appointments to help coordinate medical care. In summary, a care manager can help serve as a medical advocate to support patients with chronic conditions, and also help families communicate and understand care gaps and available resources.
