Case managers in the nursing home.

WANTED: Facility-based case manager for subacute care program. Must be clinically licensed and have experience, certified case manager preferred.

This ad is becoming very familiar in the health care section of local classified ads. Until recently, most case managers were employed by insurers or the workers compensation industry. With the advent of subacute care units accepting more medically complex patients, there is a greater need for the contributions case managers make to coordinated care.

What, exactly, is a case manager? Case management is defined by the Case Management Association of America as a "process of assessment, planning, organizing, implementing, coordinating, monitoring and evaluating health care services to respond to the individual's needs." The goal is to promote high-quality, cost-effective and optimal outcomes.

Subacute care providers in nursing homes are finding their facility-based case managers to be quite necessary, especially when dealing with managed care payors and external referral sources, in that they benefit from a seasoned case manager's knowledge of cost management strategies. Further, these positions should be staffed by clinical professionals who are highly trained to be able to communicate with the referral source, the payor, external case managers, physicians, other clinical team members, the patient and family.

The effective case manager should possess a quality of maturity, one that engenders trust and confidence. It is important also that the case manager has a working knowledge of many different health care settings and the types of clinicians and professionals that work in these settings.

Patience and tenacity are also desirable traits. Coordinating services can be frustrating, phone calls aren't always returned in a timely fashion, family members may not be in a position to assist, and information isn't always readily available.

Case managers must be flexible and able to shift gears as the needs of the patient, family, staff and services change. They often find themselves in a position that requires reprioritizing tasks and activities to meet changing objectives and goals.

Case managers play two more important roles: First, in order to better serve their clients, the subacute care provider should have a single point of accountability -- and that is, or should be, the facility-based case manager. Case managers as the reference point will enhance marketing efforts by creating relationships with referral and payor sources and thereby encouraging repeat business. Second, the case manager plays an integral role in gathering and defining information on achievable outcomes. As subacute care grows, the provider will become more reliant on soundly-based outcome data as a marketing tool.

It is not too soon to begin thinking about hiring an experienced, qualified case manager, if one is not employed on the staff already. America's health care delivery system is undergoing significant change. If universal access is implemented in the near future, it is projected that over 20 million new users will enter the health care system. Further, survival rates from catastrophic injury and illness have increased over the last 15 years. Finally, the elderly population will experience dramatic growth within the next 10 to 20 years, as we begin to see the "Baby Boom" generation become the "Greyby Boom."

It is certain, however, that with cost constraints, all levels of health care will he competing for tightly restricted dollars. Finding their way through this challenging environment, subacute care providers can travel a path already cleared by payors who have learned the advantages that case managers provide.