What is a Case Manager?I heard that question a lot after accepting my new position as a nurse case manager for a large insurance company. To be truthful, I did not know how to answer the question. I had applied for the job at the suggestion of a friend, even though I did not know what a case manager did.

Even after I was hired I still did not know what a case manager did. My new boss told me not to worry, that I had the qualities needed to be a great case manager, and that she could train me on the rest. Wow, talk about pressure. Then she handed me a book about case management and told me to read it. I was getting paid to read a book, so I didn’t complain.

I had been a case manager for about a year when I finally came up with an answer to the often asked question, “so what do you do?” My reply was, “I educate and support patients with complex medical issues and helped them to navigate the healthcare system.” Sounds good, but what exactly does that mean?

First things first, who needs a Case Manager?

Case management clients are not healthy people trying to prevent disease. They are people with either a chronic illness or injury or a complex acute illness or injury. They can range from a newborn infant born with a congenital heart condition, to a 26 year old with a spinal cord injury following an MVA, to a newly diagnosed Hepatitis C patient in liver failure requiring a liver transplant.

Educating Clients

To me, educating clients is the most important thing I do. One of the objectives of case management is to foster patient autonomy. Educating the patient gives them the information they need to make a confident and appropriate decision about their health care.

I educate them on:

  • Their disease or condition
  • Their treatment options
  • Resources available to them
  • Their healthcare benefits
  • Available providers

Supporting Clients

  • Supporting the client can come in many forms.
  • Emotional support finding resources for financial support
  • Supporting their decisions about their healthcare
  • Advocating for them
  • Providing support and resources to caregivers

Navigating the Healthcare System

Just as a ship needs a Captain to lead it from port to port and on to its final destination, a patient may need someone to help them through the vast healthcare system. It can be extremely intimidating for a person who has never been sick to suddenly be thrown into the healthcare system. All of a sudden, life as he or she knows it is over. Take, for example, a patient newly diagnosed with breast cancer.

One day she is an accountant, wife and mom, the next she is a breast cancer patient. She goes from juggling work, soccer games, and date night to juggling appointments with her oncologist, radiologist, and surgeon. She feels overwhelmed and lost in the huge healthcare system.

When she has a complication or side effect, which doctor should she call?
Her oncologist ordered Zofran for her nausea, but her surgeon ordered Phenergan. Which one should she take? Should she take them both?
Where can she get a wig? Will her insurance cover it?
Her oncologist referred her to one surgeon, but her best friend recommended another. What should she do?
Helping with these types of questions can make a huge impact on the quality of life for the client.

In conclusion, a case manager provides education, navigation and support, to patients and families with medical issues.