Q&A: Helping patients meet care goals

Q: How can a case manager match a patient with a care plan and help the patient meet planned goals?

A: Case managers must manage the care continuum as advocates on behalf of the patient and family. They must manage patients across the continuum of care by understanding and monitoring the patient contract and by moving patients along a system that is highly complex and fragmented.

To be successful, a patient must understand their goals for care. Whether focused on discharge goals from the hospital or long-term goals toward self-care, the patient, family, and healthcare team must all agree and act in a manner that leads to successful outcomes.

For patients with chronic Illness, long-term goals can be intimidating, which is why these patients benefit from consistent support and monitoring. Case managers and social workers, along with other members of the healthcare team, can help patients by working with them to develop milestones.

The spectrum of care has become exceptionally diversified, and the aim of case management is to both identify the next site of care and bridge the gaps that occur when patients move from one setting to another.

For more information, see Longitudinal Case Management: Designs Across the Continuum of Care.