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Recognizing the Role of a Case Manager

The Care Management Department at Harrington is comprised of a team of Case Managers, Congestive Heart Failure (CHF) Case Manager, Medical Social Worker, Physician Advisor, Clinical Documentation Specialist, and Secretary. Case Managers are multitasking patient advocates who coordinate quality, cost-effective care from available resources. We are focused on disease management and relapse prevention. We provide assistance within and outside of the hospital linking patients to rehabilitative and supportive services.

We are focused on disease management and relapse prevention. We provide assistance within and outside of the hospital linking patients to rehabilitative and supportive services.

The role of the Case Manager is broken into different disciplines – utilization review and discharge planning. The Utilization Review (UR) Case Manager reviews each admission and applies Interqual criteria to determine

The Utilization Review (UR) Case Manager reviews each admission and applies Interqual criteria to determine the appropriate level of care (inpatient versus observation). At times, that review requires communication with the admitting physician when the ordered admission status does not meet the ordered admission criteria. Once the status is confirmed, and the insurance company has been notified, the Interqual and supporting documentation from the medical record is faxed to the insurance company for approval. Concurrent reviews are faxed daily or as directed by the insurance company. Some admissions are denied by the insurance company, at which point they are reviewed and appeal letters are written.

Using a collaborative process of assessment, planning, care coordination, evaluation and advocacy, the discharge planning Case Manager visits every patient, completes a discharge assessment and makes appropriate referrals to home health providers or skilled nursing facilities. The patient is always given a choice of which facility or agency they prefer; whenever possible, family and caregivers are included in the discharge planning process.

Case Managers assist patients in completing a Health Care Proxy. In the event a person is unable to make a decision for themselves, the Health Care Proxy is invoked and the agent is then granted the right to make decisions for the person. Case Managers believe that every person over the age of 18 should have a Health Care Proxy on file with their Primary Care Physician. The discharge planner also makes referrals to Elder Service agencies for private services such as meals on wheels, homemaker services, companions, or transportation. It is the discharge planning Case Manager that works closely with patients, families, skilled nursing facilities, and the Credit Department to assist with placement into

The discharge planner also makes referrals to Elder Service agencies for private services such as meals on wheels, homemaker services, companions, or transportation. It is the discharge planning Case Manager that works closely with patients, families, skilled nursing facilities, and the Credit Department to assist with placement into long-term care.

The Care Management Team is an integral part of the healthcare team. We work in collaboration with the patient, family, caregivers, and multidisciplinary team as well as the post-acute providers and insurance companies.

While we recognize our contribution to patient care October 8-14, we would be happy to answer any of your questions at any time regarding our role in patient care.

Deb Umanzor, BSN, RN, CCM, is the director of Case Management at Harrington HealthCare System.

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100 South Street, Southbridge, MA 01550 | Directions >>
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