Most people do not think about care management until they or one of their family members becomes chronically ill or suffers from multiple conditions and require more than basic care. That’s when a Care Manager may come into the picture. Understanding treatment plans, developing collaborative care plans, and navigating resources can be overwhelming. For patients and caregivers, Care Managers are a key contact to help coordinate and manage care.

As the titles Care Coordinator and Care Manager are often used to describe the same roles, there may be a distinction between a Care Coordinator and a Care Manager in some clinical settings.

Many definitions try to encompass everything that could be associated with care management. The Robert Woods Johnson Foundation (RWJF) defines Care Management in the “Care Management of Patients with Complex Health Care Needs” synthesis project as the following:

“Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aim of improving patients’ health status and reducing the need for medical services.”

Adding a Care Manager to the care team can make a significant impact in improving patient-centered quality care. The personal relationship between care manager and patient is vital for a patient and caregivers to stay on track with a collaborative care plan. It is essential to remind ourselves that the patient is the most critical member of the team, and good patient-centered care includes listening to, informing and involving the patients in their care.

Adding a Care Manager also benefits the care team by reducing the care team’s stress, as patient education and engagement and resource navigation are often layered on the duties of medical assistants and registered nurses, who are already juggling with multiple tasks.

Effective care coordination which may be more focused on episodic or periodic changes in health status, can help health systems reduce ambulatory sensitive admissions, readmissions and address overuse or misuse of high cost, low value care, ultimately impacting the total cost of care. Patients needing additional care management support over a longer term are often enrolled in longitudinal care management.

Having a Care Manager as part of the care team is even more critical in COVID19 pandemic. Identifying and engaging with high-risk patients to ensure access to needed prescriptions and care options is vital.

Implementing care management into the team can be challenging as it involves changes in the roles and tasks. It is essential to have a good plan in place for implementation.

Reference:
Goodell S, Bodenheimer TS, Berry-Millett R; “Care Management of Patients with Complex Health Care Needs” Robert Woods Johnson Foundation, 2009

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