Module C: Key Components to CM Success

CE Credits: 1.4

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This module looks at the balance that successful case managers must strike as they advocate for the patient while also helping to facilitate the most effective, timely treatments. First, the module explores how a CM must navigate resources for patients and understand (and often negotiate with) commercial and government insurance plans, while also troubleshooting for medical errors or unnecessary delays in treatment. The module also details why efficient treatment is vital for the patient, in terms of avoiding longer hospital stays. The module concludes by examining the various ways that CMs can measure success, including clinical and cost outcomes.

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Learning objectives: After completing this module case managers will be able to:
» Explain how case managers enable the strategic management of cost and quality
» Relate the case manager’s advocacy obligation to the need for assertive resource management
» Respond knowledgably about the risks associated with hospitalization and the value of timely transitions of care
» Describe some of the measurable outcomes used to evaluate successful care management

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Advance your professional practice: As case managers, we strive to get the best care for our patients, and to support our healthcare organization so that it can offer the most effective and streamlined treatments possible. By understanding how the fragmented healthcare system affects our patients—from insurance coverage to the pitfalls in transitions of care—we can offer solutions to meet our patients’ needs.

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Improve organizational performance: By understanding all of the possible pitfalls that can present themselves in a patient’s care—from denied coverage to hospital-acquired infections and misguided transitions of care—we can be better prepared to improve and streamline our services to patients. When the team understands those factors and supports case mangers as they advocate for patients, we can work toward better outcomes for our patients and a stronger team within the healthcare organization.