✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on July 11, 2025.
Case managers ensure that clients receive the right level of care by understanding the rehabilitation and medical services various settings provide.
Inpatient rehabilitation may be provided in the following settings:
- medical hospital
- long-term acute care hospital
- inpatient rehabilitation hospital
- skilled nursing facility
Regardless of the setting, case managers oversee client care throughout rehabilitation, ensuring they receive necessary services and support while adhering to Medicare or other payer guidelines. They lead or participate in interdisciplinary team meetings during which they monitor progress, confirm post-discharge needs, address service gaps, and identify needed resources. Case managers facilitate communication among the patient, family, and care team on recovery goals, discharge planning, and post-discharge care.
Rehab case manager transitions of care coordination responsibilities include:
- Educating clients and caregivers about discharge dates, post-discharge care needs, and available resources
- Ensuring patients and caregivers receive training and education on post-discharge care, caregiving at home, and home safety
- Securing insurance coverage for and arranging home health and durable medical equipment
- Coordinating follow-up care, such as outpatient therapy and follow-up appointments
- Connecting clients to community resources, including transportation services, caregiver support, and home modification programs
- Ensuring medication education and reconciliation are completed
- Ensuring a safe home environment with necessary modifications or support
This article shares a portion of the information covered on this topic in CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025). For more details on this topic and related concepts, purchase your copy at CCMCertificationMadeEasy.com
