Case Management Services: What You Need To Know

Growing old means reaching another milestone and starting a new chapter in the book of life. But despite the many joys of reaching the golden years, there’s no denying that aging also comes with its own unique trials.

For one, your body is not as strong and healthy as before, making it a challenge to accomplish everyday tasks. There’s also the issue of the mind’s gradual cognitive decline, making it even more difficult to age in place and live independently.

What’s worse is that some seniors who require more support and medical attention don’t have any access to quality healthcare.

Fortunately, we have case management services and case managers to help seniors get the good life they deserve. Read on to learn more about case management services.


If you have any additional questions, here are some we frequently get from clients. FAQ


What Is Case Management?

According to CCMC, case management refers to a collaborative practice that plans, coordinates, monitors, and evaluates a wide array of services required to meet a senior’s health and overall needs.

In simpler terms, case management services aim to improve seniors’ health and wellness by meeting their every need. This way, they can reach the highest quality of health and life they deserve. Generally, its main goals are to:

  • First, help you or your loved one achieve an optimum level of wellness.
  • Second, help you or your loved one reach functional capability for self-management.

Some of the services provided may involve:

  • Medical, mental, and behavioral health
  • Employment
  • Housing
  • Social services
  • Access to quality education
  • Other essential health and human services

A case manager will be responsible for coordinating the client with the services and resources they need.

What Does a Case Manager Do?

A case manager’s primary role is to coordinate the care of seniors to appropriate providers and facilities. They will also organize and evaluate the best care option to meet your loved one’s needs.

Moreover, case managers provide senior clients with safe, timely, and cost-effective services. Some of the things they do include:

  • Meeting the senior patient and their loved ones to best assess their needs.
  • Forming a care plan to meet the patient’s health and life needs. For example, looking for the best assisted living facility for them or applying them to a benefit program.
  • Communicating with both the senior client and the involved institutions in their care
  • Track the patient’s progress and regularly contact them to evaluate their overall welfare.

Additionally, case managers may come from different educational or professional backgrounds. For example, they can be nurses, social workers, behavioral counselors, and mental health advocates.

What Is the Process of Case Management?

Case managers follow a 9-phase process to provide health and human services to seniors in need. This includes:

1. Screening

The screening process involves identifying your or your loved one’s needs to know what services they can benefit from. During the screening process, the case manager will gather information about:

  • The senior client’s physical, mental, and emotional health state
  • Socioeconomic and financial status
  • Home environment
  • Health insurance coverage
  • Psychosocial support system
  • Self-care ability

2. Assessing

During the assessment phase, case managers will review the information gathered during screening and identify the key problems of their clients to build a specific case management plan.

3. Stratifying Risks

Based on health assessments, this phase involves classifying the senior patient into one of these three categories: low, moderate, or high risk.

4. Planning

The planning phase entails building a case management plan of care for your senior loved one. This action plan should be complete with specific objectives and actions, like services or treatments, that meet the senior’s needs.

5. Care Coordination

Here, the case manager will implement the care plan by collaborating with different health and human services providers. 

Additionally, this includes guiding the senior client on an ongoing basis as they engage with the different institutions that would provide the care and resources they need.

6. Following-Up

Case managers will then evaluate the progress of your senior loved one and the outcome of the services implemented. Finally, they will monitor and reassess the senior’s condition and see if they need to bring some changes or leave the plan of care as it is.

7. Transitioning

If the follow-up phase yielded a positive outcome, the case manager would then arrange for transitional care. This means moving your loved one to another level of care based on their condition and needs. 

For example, after successful hospital treatments, the senior client may be moved to their home to continue their recovery.

8. Communicating Post-Transition

Case managers will check on their clients to know about their progress, health condition, and care concerns.

9. Evaluating

This involves the evaluation of the implemented care plan. Plus, this is where case managers disseminate result reports to the agencies involved in their client’s care.

old lady discussing with a doctor

Learn more about this at Care Partners at Home

Here at Care Partners at Home, your well-being is important to us. We know how hard it is to navigate the healthcare system and look for the services and resources that you need. So, we are here to bridge that gap for you with compassion and true expertise. 

If you think you or a loved one requires case management services, don’t hesitate to contact us at (888) 336-5447. We also provide other services that you might need, such as:


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