How can you identify patients who would benefit from case management?

1 Assess the patient's risk level

One of the first steps to identify patients who would benefit from case management is to assess their risk level for poor outcomes, such as hospitalizations, readmissions, emergency visits, complications, or non-adherence. You can use various tools and criteria to measure risk, such as clinical indicators, utilization patterns, psychosocial factors, and self-management skills. For example, you can use the LACE index to score the likelihood of readmission based on length of stay, acuity, comorbidities, and emergency visits. Patients with high risk scores may benefit from case management to prevent or reduce adverse events.

3 Consider the patient's readiness and willingness

A third step to identify patients who would benefit from case management is to consider their readiness and willingness to engage in the process. You can use a readiness ruler or a stage of change model to assess the patient's level of motivation, confidence, and commitment to change their behavior or situation. You can also ask the patient about their perceived benefits and drawbacks of case management, and their interest and availability to participate. Patients who are ready and willing to work with a case manager may benefit from case management to enhance their activation and empowerment.

4 Consult with the patient's providers and caregivers

A final step to identify patients who would benefit from case management is to consult with the patient's providers and caregivers. You can communicate with the patient's primary care physician, specialists, nurses, pharmacists, social workers, and other members of the care team to obtain their input and feedback on the patient's condition, needs, goals, and plan of care. You can also involve the patient's family, friends, or other informal caregivers who may have valuable insights and perspectives on the patient's situation and preferences. Patients who have complex or fragmented care, or who lack adequate support and coordination, may benefit from case management to improve their communication and collaboration with their providers and caregivers.

5 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?