Case Management

What is Case Management?

It is a process, managed by your healthcare team, to help you and your family find medical solutions. The case manager is your team coach and advocate. Together, you develop a plan of care to promptly control your illness, injury, or situation, and navigate through the maze of medical care progressing toward your medical goal.
Generally, patients with complex problems and considerable medical expenses receive case management support. Problems may be one or a combination of medical, social, financial, or mental health.

Who is eligible?

• TRICARE Prime patients
• Participation is voluntary

Diagnoses considered

• AIDS
• Bone marrow transplants
• Major burns
• COPD
• Diabetes
• Dual medical and psychiatric diagnosis
• Dual psychiatric and substance abuse diagnosis
• Extended hospitalization
• Head trauma
• High drug costs
• Neonates in NICU
• Neoplasms
• Spinal cord injuries

Other categories considered

Diagnostic categories

• Catastrophic illness or injury
• Chronic or terminal illness
• Multiple medical problems

Patient status

• Functional / Physical deterioration
• Lack of family / Social support

Patient behaviors

• Non-compliance / resistance to treatment
• Inability to follow treatment

General indicators

• Repeat admissions
• Unexpected re-admissions
• Multiple Emergency Department visits / Providers

Why would I need Case Management?

The need for case management services is determined through a collaboration between you, your family or caregiver, your health care team, and your provider. This collaboration will include a comprehensive assessment of your health, psychosocial needs, and use of health care services and resources.

Case Management can help by

• Coordinating your care
• Assessing, planning, and facilitating services for you
• Evaluating your options
• Advocating on your behalf

You or your family member may need Case Management if you have

• Instability with chronic health problems
• A serious terminal illness
• An increased need for different provider specialties. A branch of medicine or surgery that a doctor specializes in. due to multiple diseases or conditions
• A need for more support and education during a critical period

Who are Case Managers?

Case managers are registered nurses who can help you and your family figure out complex health care and support systems. They will work with you to coordinate the services and other community resources you need.

They can help

• Provide advocacy, support, and education
• Reduce burden and streamline appropriate utilization of care
• Partner with members of your healthcare team to assist in coordination of your healthcare needs
• Monitoring for progress and desired outcomes

How long will Case Management services last?

Services last until your Case Management goals are reached or until you and your case manager decide they are no longer necessary and/or helpful. Case management may be resumed at a later time if needed.

Is there a fee?

Case management is a TRICARE / Prime benefit. There is no additional charge and no billing to your insurance for this service. 

Referral to Case Management

Electronic Referral: Ask your Primary Care Manager (PCM) to write a consultation to Case Management services or call the phone number listed for this clinic’s case management services.

Who will be my Case Manager?

You will work with a registered nurse. Everyone has the same goal — to help you reach optimum health as soon as possible.

Will my Primary Care Manager be informed of these plans and services?

Your PCM is part of the team that helps you make plans and decisions about your health goals. Based on these goals, your case manager develops a plan and continually updates it as you progress. The PCM and you have the final say about your care.

Along the way, we share with you

• Your progression according to the case management plan
• Our professional evaluation of family dynamics affecting response to treatment
• Medical insurance coverage as it impacts identified medical needs

Beneficiaries receiving Case Management Services have the right to the following:

• The right to be treated with dignity and respect and to have problems or questions addressed and resolved in a timely manner.
• The right to have medical, financial and personal information treated in a confidential manner and released only as necessary to authorized persons.
• The right to receive appropriate and quality medical care and case management services that are subject to accepted medical or nursing standards of care without regard to age, race, color, creed, physical disability, national origin, sex, sexual preference.
• The right to be told in advance of receiving care about the services that will be provided, who will provide the service, identity of the responsible Payer of services, other choices that are available, and the consequences of these choices, including the consequences of refusing these services.
• The right to refuse treatment or services, including case management services and the implications of such refusal relating to benefit eligibility and or health outcomes.