People with serious health issues are increasingly turning to Care Managers, also known as Care Coaches or Health Advocates, to help them navigate the issues of diagnosis, treatment, and management of their health problems. Due to the complexity of our current health care system, it has become increasingly difficult for individuals to effectively access the services. Since cost containment procedures were implemented in the mid-1980s, the financial incentives imposed upon physicians and hospitals have interfered with their serving as patient advocates in the ways they once did. These changes have created a new member of the health care team, the Care Manager.

Why Care Management?

When an individual becomes ill, especially with serious or subtle symptoms or behaviors, it can be very difficult for the person and their family to find their way to and through their health care system. Insurance issues alone present formidable barriers to many people seeking care. Advances in medical diagnosis and treatment, along with consolidation of hospital systems and competition between systems, has created the need for people with the skills to navigate these complex organizations to obtain desired outcomes.

What Is Care Management?

Sometimes referred to as Care Coaching, most people are familiar with coaches in team and individual sports, such as baseball, football and ice skating. One of the most important roles of a coach in any sport is to teach players the rules of the game and help them expand their skill in the sport. The Merriam Webster Online dictionary defines a coach as one who instructs or trains; especially one who instructs players in the fundamentals of a competitive sport and directs team strategy. The Cambridge Online dictionaries (COL) goes a step further and identifies coaches as teachers, such as someone whose job is to teach people to improve at a sport, skill, or school subject. COL states that coaches give special classes in sports or a school subject, especially privately, to one person or a small group.

The challenges in accessing high quality health care in the current environment have resulted in the development of a new type of coach. Care Managers, Care Coaches, or Health Care Advocates know the “rules of the game” of health care and the language of medicine. They use a structured process and partnership to help clients and families identify their options and to make the best use of available resources. Care Managers wade through information from doctors and other providers, know what questions to ask, and help you learn to cope with the issues caused by illness and disability.

Care Managers provide an unbiased source of medical information because their responsibility is to their client, not to a health system or other provider. Care Managers don’t replace physicians but rather provide the information and support needed by clients and families to make fully informed decisions, better manage their health needs, and navigate effectively through the health care system. They provide education, motivation, support and help you achieve your goals.

What Do Care Managers Do?

A typical approach used by a Care Manager would include any or all of the following activities as requested by the client and family:

  • Meet with client to discuss medical history, current health concerns, symptoms and medical treatment plan
  • Clarify issues of concern and identify ways to resolve those concerns
  • Assist in obtaining medical records if needed
  • Review medical records with client
  • Meet with the client and physician(s) to discuss client’s concerns and to learn what options are available
  • Arrange referrals to medical specialists for additional options
  • Arrange for therapeutic services as ordered by physicians
  • Arrange for community services and equipment as needed
  • Provide education and support to client and family

What Are The Benefits Of Care Management?

Clients can expect some specific outcomes and benefits when working with a well-qualified Care Manager. The information provided by collaboration with the Care Manager will enable clients to make well-informed decisions that best meet their needs. This reduces fear and anxiety and focuses efforts on maximizing wellness and not on being sick. These include:

  • Clear information from physicians about diagnosis, treatment, and prognosis
  • Care options regarding treatments and health systems
  • Insurance coverage regarding care
  • Timely access to needed services
  • Well-coordinated care
  • Emotional support

Who Provides Care Management?

Registered nurses, along with health care providers from other disciplines, are very effective care managers. Nurses speak the language and know the culture of health care organizations. Registered nurses have the professional expertise to effectively access complex health care organizations and to cut through the red tape and bureaucracy that often exists. In everyday practice, nurses interact with providers from every medical discipline to facilitate their clients’ diagnosis, treatment, recovery and rehabilitation. And at the end of life, nurses provide hospice care to support the client and family.

Nursing education and practice are focused on the “whole” person and the family unit, not on one organ system as is the case with physicians who specialize in one medical discipline. In addition, nurses are trained to draw on the strengths and abilities in clients and families and not focus solely on problems related to health concerns. Nursing’s major focus is to help clients and families resolve concerns and function as well as possible as individuals and families.

When Is A Care Manager Needed?

Individuals and families who are having difficulty obtaining a clear diagnosis or treatment plan often benefit by working with a Care Manager. People with chronic conditions and disabilities can often improve their level of functioning through collaboration with a Care Manager. People with some of these conditions will usually benefit from working with a Care Manager:

  • Cognitive impairments: Alzheimer’s disease or other forms of dementia
  • Cancer, especially a new diagnosis
  • Physical impairments: paralysis, immobility, amputations
  • Chronic health problems: diabetes, arthritis, heart disease
  • End of life issues

How Can I Find A Care Manger?

To obtain maximum benefit from a Care Manager, it is important to find one who works for the client and is not employed by a provider organization. There is no state or national certification or licensure for Care Managers, so anyone with an interest can enter the field. Choosing a Care Manager should include determining whether the prospective Care Manager has a current valid license in a health care discipline, such as nursing. The Manager should have many years of experience in serving clients with similar needs in the geographical area where the client lives. They should be able to provide strong references. It is wise to enter into a written service agreement with the Care Manager that identifies fees, responsibilities, privacy issues, services to be provided, how to terminate services and a method of resolving disagreements.

Matrix Care Management In Action

Mr. C., age 78, was admitted to a nursing home after being hospitalized after falling and sustaining complications. His family had many questions about his needs as the time of his nursing home discharge approached. Could he leave the nursing home? Where would he live, what care would he need, and who would provide for those needs?

To get help with answering these questions, Mr. C’s family contacted a Matrix Care Manager who met with Mr. C and the family while he was still in the nursing home. To obtain information to answer these questions, the Care Manager reviewed Mr. C’s current situation, his medical history, his and his family’s goals and wishes, Mr. C’s strengths and abilities, and later conducted a home safety evaluation. Several care options ranging from returning home with services or moving to an assisted living residence were shared with Mr. C and his family.

The option chosen by Mr. C and his family was for him to return to his home where he lived with his son who worked during the day. To meet his needs and provide for Mr. C’s safety, the Care Manager advised having a caregiver come into the home for two to three hours during the day when his son was at work. The caregiver’s role was to prepare a noon meal, ensure he took his medications as ordered, and take him on outings into the community. The Care Manager provided the family with a list of local agencies that had the level of care providers that Mr. C needed and assisted in implementing home care services at the time of Mr. C’s nursing home discharge.

It was noted during the assessment that Medicare had stopped paying for physical therapy at the nursing home. However, with input from Mr. C and his family, the Care Manager realized that Mr. C had not returned to his “baseline” abilities in strength and balance. These impairments increased his risk for falling – exactly what caused him to be hospitalized initially. The Care Manager was able to guide the family to possible options that would enhance Mr. C’s safety and improve his strength and balance. They chose to implement ongoing in-home physical therapy and an at home exercise program.

Mr. C continued to have changes in his needs related to his many chronic illnesses. The Care Manager explained medical terminology and interfaced with the physician and other members of Mr. C’s care team to assure accurate information was relayed to all team members, including his family. This included explanations of how medications work for each particular condition, why using prescribed durable medical equipment was essential and potential complications if those directions were not followed consistently. As a professional nurse, the Care Manager provided regular assessment of Mr. C’s health and functional status on a regular basis, and addressed health changes promptly with the primary physician. These interventions reduced falls, medication errors, and other complications so Mr. C could continue living in his own home.