Why refer???
The more complex a patient’s / client’s needs, the more clinically complicated the case, the more providers involved, the more decisions to be made, and the more pre-existing problems, the greater the likelihood case management will have tremendous impact on the outcomes of the case. Included in the list of reasons that make cases appropriate for case management are the potential for fragmented care because of the number of providers or services involved, the confusion and anxiety felt by most people as they attempt to make their way through the health care system, or lack of experience and knowledge to make informed health care decisions. Certain catastrophic and high dollar cases are known to benefit from case management regardless of the type of insurance plan. They may include spinal cord injury, back injury, low back pain, traumatic brain injury, burns, high risk pregnancy, high risk neonate, technology dependence, transplants, AIDS, and oncology patients. The presence of a pre-existing condition or secondary diagnosis may make a case appropriate for referral. Other cases known to benefit from case management are those with requests for unproved, controversial or unsafe treatment, excessive length of disability based on diagnosis, requests for expensive DME purchases, repeat hospitalizations and surgeries, and any apparent or questionable abuse or overutilization of health care services.