CASE-MANAGEMENT - HIGH-INTENSITY CARE FOR FRAIL PATIENTS WITH COMPLEXNEEDS

Case management has evolved beyond the functions of discharge planning and utilization review to a role of managing the delivery of services for populations across settings. The two forces driving this change a re the growth of Medicare managed care and the increasing numbers of f rail older patients with chronic disease. Necessary components of case management include a system of risk identification: an ability to lin k information, physicians and other providers; an interdisciplinary te am approach; and the ability to follow identified older patients over time. In high intensity/low volume models, each case manager works dir ectly with a small number of patients for a given episode of care or o ver time.