Experts Can Advise You —
And Push for Your Best Care

J. Greene


      When Nancy Skinner’s mother began, at age 84, to suffer from dementia and some physical disabilities, Skinner realized she needed some help to find the best care for her. And when her mother was scheduled to get out of the hospital while Skinner was out of town on business, she decided what kind of help that would be: She hired an independent case manager.
      If you haven't heard of case managers, you're not alone. They're probably the best-kept secret of health-care advocacy. Case managers are generalists with expertise in both medicine and insurance who can look at the big picture and negotiate on a patient's behalf to be sure they're getting the best care at the right time.
      The field grew in the 1980s as insurance companies hired case managers — often registered nurses — to be sure a patient's care was done efficiently and according to the insurance company's rules. In recent years hospitals have hired case managers to keep costs down.
      But now, happily for patients, individuals can hire an independent case manager to work on their own behalf. For an hourly fee, a case manager will review your medical and insurance situation and recommend a plan. Case managers are being used most frequently by families of the elderly, who face a dizzying array of options these days: Does a sick parent need to be in the hospital, a nursing home, an assisted-living facility, adult day care or some other new concoction of the health-care marketplace? For members of the "sandwich generation," these issues often arise at the same time they're trying to raise children and run a two-income household. Handing over some of the research and legwork to someone who knows the system — and can manipulate it — can be a very attractive prospect.
      That's how it worked out for Skinner, who hired a case manager with expertise in geriatrics for her mother even though Skinner has the expertise herself (she's a case manager and the president of the field's professional society). "Sometimes you need someone who is not emotionally involved in the situation," Skinner says. "Caring for your parents' needs can become a full-time job. Many of us can't do that."
      Among the things the case manager took care of were:

bulletWorking with a discharge planner at the hospital to decide whether Skinner's mother should go back to her assisted-living facility or to a nursing home.
bulletArranging for a home-care worker to come in and help her mother a few hours a day when it was decided she could go home, but not without some help.
bulletMaking sure the doctors at the hospital and at the assisted-living facility were on the same page.
bulletEvaluating health-care facilities and comparing their services and costs.

      While the hospital and the assisted-living facility each had case managers to help coordinate care, they were responsible for many patients in a large facility, and Skinner wanted to be sure she had an advocate who knew all the details of her mother's situation.
      "I needed someone whose sole allegiance was to my mother," she says.
      It all may sound good, but can you afford it? Skinner thinks the final cost was worthwhile, considering the alternative, that her mother could have ended up in the wrong facility, getting sicker or paying for care she didn't need. Skinner paid $65 an hour to the case manager, who spent 10 to 15 hours on Skinner's case over a month's time. Case managers' rates vary by region, ranging from about $50 to $120 per hour.
      Some independent case managers offer a package deal for families with an ailing relative. For instance, Maura Davis is an RN and certified case manager who runs an independent case management business out of Duxbury, Mass. She charges $175 for a 90-minute functional assessment; and $350 for a three-hour session that also includes specific recommendations of a nursing home or other facility, and a roster of appropriate health-care specialists and financial planners to help with estate planning. Beyond that, she charges $65 an hour to "run interference," which often is only a few hours' work. A major crisis, Davis says, will usually take up about eight hours of a case manager's time.
      While Davis' business is being marketed to families of the elderly, case management can also be helpful for people in other situations, she says, such as someone with a life-threatening disease, recovering from a serious accident, or with a chronic ailment.
When a patient is having a major disagreement with an insurer, it can be more effective to hire a case manager as an advocate than a lawyer, Davis argues. "You're less likely to create a hostile environment," she says. "As soon as most folks know you have a case manager on your behalf, you'd be surprised how they say, 'Yeah, yeah.' I'll call the insurance company and say, 'I know you can flex the benefits for an extra day,' " says Davis, herself a former insurance company case manager.
      Before hiring an independent case manager to go to bat for you, check credentials. There are several types of certification for case managers, one offered by the Case Management Society of America, which tests applicants in both their clinical and financial knowledge. Ask questions like:

bulletDo you have a nationally recognized certification?
bulletWhat is your health-care background (nursing, social work)?
bulletHow long have you been in case management and what is your experience?
bulletHow much do you charge per hour and do you charge the same rate for travel time as you do for coordinating care?
bulletHow much time do you think this case will take?
bulletDo you have references?

      Probably the hardest part about hiring a case manager is finding one. Because it's such a new trend, there aren't any easy referrals available, although the case management society expects to have a referral system in place by the end of the year. Another organization, the Geriatric Case Managers of America, has a directory of its members that can be obtained by calling the Tucson, Ariz.-based group at (520) 881-8008. You can also try asking the local hospital whether it has a list of independent case managers, sometimes also called care managers. Check with the hospital's patient advocate or discharge planning staff.
      Davis is convinced case managers will help level the playing field between patients and the "health-care industrial complex," as she calls it. "When I see these stories about people who have trouble getting care, I ask why didn't they get a case manager? It breaks my heart that people don't know it's available."


Local Case or Care Management is available as a free service with our Long Term Care coverage and is highly recommended. You are Not obligated to use this service or to accept any of their advise or recommendations. However, you no doubt will find that this service and knowledge will be of great value to you.

Also see FAQ's  No. 6


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