Types of care management services

Part of the structure of the care manager role is clarity on the care manager’s main types of activity. Some of that clarity comes as the practice moves toward the mindset of each individual working to the top of his/her license or certification. The care manager should spend time on the things s/he is uniquely qualified to do. Here, we list the five main categories of care management services.

  1. Transitions of care
    The care manager helps patients manage their care transitions between and among health care providers and settings (e.g., transitioning from hospital to home), including referrals to other providers. Care managers also provide follow‐up after an emergency department visit, and after discharges from hospitals, skilled nursing facilities, or other health care facilities. A large task in this category is medication reconciliation, where the care manager reviews all medications, adherence, financial resources to pay for medication, and identifies potential drug interactions. A comprehensive assessment of the patient’s medical, functional, and psychosocial needs is conducted by the care manager.
  2. Care coordination The care manager works with patients, families, and caregivers to identify potential gaps in meeting the patient’s functional, psychosocial, behavioral, and financial needs. Care managers assist patients with getting the appropriate delivery of health care services to achieve optimal health or end‐ of‐life outcomes. This includes calling health care agencies or specialists on behalf of patients. This is different from, but overlaps with, transitions of care services. Care coordination occurs with or without the patient actually going to another care facility.
  3. Education and follow-up
    The care manager helps patients manage their chronic conditions by providing education and continuous follow-up. For example, the care manager may educate newly diagnosed diabetic patients, teach insulin injection, and have patients keep a blood sugar log and food record. The care manager follows up with patients usually bi-weekly or monthly via telephone, patient portal, or face-to-face when the patient is at the practice seeing his or her PCP. The care manager tracks how the patient is doing over time.
  4. Health behavior change counseling and self-management goal setting
    The care manager works with the patient and the patient decides what health behavior change(s) the patient would like to make. The care manager uses counseling/coaching techniques such as motivational interviewing to empower patients to facilitate behavior change (versus telling the patient what to do). The patient identifies one or two goals to work on and these are recorded in the medical record. The patient decides on how often follow-up visits will occur with the care manager to receive ongoing support with goals and to track progress.
  5. Connecting patients with community resources
    The care manager identifies individual patient needs including gaps in care, and connects patients with necessary resources that are often life changing (e.g., durable medical equipment, home health care, mental health services,
    and diabetic classes).

There is really no right or wrong approach regarding the distribution of time the care manager spends in each of these activities, and they in fact often overlap. The key is clarity on the goals of the care management program and which activities support those goals.

By Complete Care Management, Inc.