Care Management is a philosophy of care that emphatically centers on the person. Rather than attempting to grapple with a complex system of disconnected (and potentially contradictory) care
options, and then determine where an older adult might fit into the maze — care management starts with the person — and crafts the
appropriate care plan around them.
A care management team or a care manager (CM) will evaluate an individual’s unique needs, plan proper strategies, keeps family members and health teams fully informed, and make
necessary adjustments, accordingly. But the patient never moves from the center of focus. Indeed, when all issues of care (and prevention) revolve around the person, every aspect of care is enhanced, and outcomes are consistently improved.
In this way, managed care is:
more coordinated / less disjointed
more interactive / less isolating
more accurate and efficient / less expensive and time consuming
more proactive and responsive / less reactive and 'clinical'
Jewish Family Service believes that the fundamental elements of care management are as follows:
A dedicated care team or care manager
A comprehensive care plan (this includes hospital-to-home plans, when transitioning)
- Development of long- and short-term treatment plan
- Implementation of plan
- Monitoring of plan
- Reassessment of plan (repeat...)
- Strong patient engagement, spurred by information and education
- Advocacy and decision support for clients and their families
- Family caregiver coaching (and respite education, when required)
- Quality control and cost containment
Expanded communication between patients and healthcare professionals
- Accessibility — when appropriate and/or possible, care is 24/7
Care coordination with community agencies and/or professional service providers
- Linking patients with community programs and applicable entitlements such as housing, financial, and legal services; transportation; self-management programs, and
In focusing the light of healthcare where it belongs — JFS
care managers can provide answers to patients and families at a time of potential uncertainty. By implementing a holistic, patient-centered approach to care — worry and expense
will be minimized, engagement and awareness will be boosted, family stress will
diminish, overall satisfaction will increase, community connections will be enhanced,
and better outcomes will result!