Case management services are designed to assist patient and family members with continuing care arrangements that may be necessary following discharge from the hospital. Case managers work with physicians, nurses, physical therapists and other members of the health care team to identify and coordinate alternative care or services that will assist in recovery.
Services arranged by case managers include home health referrals, medical equipment, rehabilitation services and nursing home placement. Case managers also supply other information and referral services, which connect the patient with appropriate community organizations that may be of assistance.
Generally, when a case manager is assigned to a patient, he or she is made aware of the patient's needs following discharge. After an interview with the patient and other members of the health care team, the case manager will formulate a mutually agreed upon plan of care and exert efforts to put the plan into action. Plans will be modified if a patient's needs change.