Case Management as Part of Patient Navigation
Patient navigation services are an exciting and value-packed specialty field in the world of healthcare services. The model has created opportunities for business operators in the healthcare field, streamlined processes for providers, and increased access for patients with a range of complex specialty medical needs.
One crucial element of patient navigation that sometimes goes overlooked is case management. Here, we will look to effectively define both patient navigation and case management and explain how the latter is a critical component of the former.
What Is Patient Navigation?
Patient navigation is a highly individualized approach to managing complex or serious healthcare situations. Its goal is to make the process of making healthcare more manageable for a patient who may be overwhelmed or otherwise unable to coordinate their own care effectively.
It can be achieved by assigning a “navigator” who will work almost like a personal assistant for the patient. In addition, today’s innovative patient navigation models also make use of automated technology, mobile apps, and networked platforms to connect patients, navigators, and healthcare systems.
A common example of a suitable candidate for patient navigation services is a cancer patient with underlying medical issues who needs to work with a variety of specialists. Such a patient could be assigned a patient navigator to help them successfully navigate their chemotherapy appointments and other treatments.
How Does Patient Navigation Work?
Patient navigation can assist a patient in a variety of ways:
- Booking and managing appointments (sometimes across different healthcare systems)
- Management of government or private health insurance benefits
- Assistance managing prescriptions and refills
- Helping to seek referrals or access other resources
- Explaining processes related to medical or billing procedures
- General assistance overcoming the many barriers inherent to the American model where each patient needs to work with various private healthcare providers.
- Facilitating safe transitions into and out of care or between different care models
- End-to-end support throughout complex and stressful medical situations
- Connecting family members with resources
- Interfacing between various healthcare systems and specialty providers
- Liaison for outpatient treatment programs
- Patient Advocacy
It’s important to note that patient navigation is not merely a value to the patient themselves. Some providers also offer direct support to families and caregivers. It also increases efficiency for healthcare providers and extends the reach of the healthcare organization.
What Is Case Management?
Case management, when not narrowed down to a particular context, is a rather open-ended and broadly applicable concept. The Commission for Case Manager Certification (CCMC) defines case management as a dynamic process that is both professional and collaborative. The process can be used to assess, monitor, and evaluate just about any situation (i.e., a “case”) and then help to coordinate and implement a response (i.e., “managing” the case). In this way, case management seeks positive outcomes for the patient and organization alike and increases the overall value of the operation.
This philosophy of evaluating and improving on a case-by-case basis is, of course, applicable to a wide variety of situations.
Case management as a fundamental concept is found as a defining feature in fields such as:
- Social work
- Criminal justice
- Project management
- Mental health/psychology
- Substance use treatment
- Medical diagnosis
What Does Case Management Mean in the Context of Patient Navigation?
With a solid understanding of each term, it becomes evident how case management is a core aspect of patient navigation. Individualized case management applied to patient navigation models is a powerful tool that leads to a more equitable and manageable healthcare landscape for patients who face significant barriers in accessing the healthcare they need.
The concept of case management is so foundational to effective patient management models that there is arguably even some overlap in the two definitions. An effective patient management model cannot exist without effective case management at the core of the system. A competent and experienced patient navigator is essentially a specialized type of case manager.
Difference Between Case Management and Patient Navigation
Case management in patient navigation systems should not be thought of as a short-term solution for someone experiencing an acute medical situation. Rather, this element will be integrated into a holistic, long-term approach to lifelong health and wellness. Case management will remain available for as long as patient navigation services continue to be needed.
Patient navigation should be approached as an end-to-end process, but obviously, those endpoints can look quite different from one patient to the next. Even specialized patient navigation operations that work with specific types of patients or providers (e.g., a patient navigation provider who focuses on serving cancer patients undergoing chemotherapy) will see a great deal of variance in timelines and treatment plans.
This is due to the highly individualized nature of both patient
navigation and case management services. An effective patient navigator will not only understand and embrace this role but also be able to explain it fully to the patients they serve so that the scope of their services is not misunderstood.
Case management is typically provided by healthcare professionals, while navigation is typically provided by laypeople. Case management focuses on clinical care and coordination, while patient navigation focuses on social support and advocacy. Case management is typically disease-specific, while navigation is typically individualized. Finally, case management is typically reactive, while patient navigation is typically proactive.
Patient navigation has been shown to be an effective intervention for reducing disparities in access to care and improving health outcomes. In contrast, case management has been shown to be less effective in reducing disparities and improving health outcomes.
One reason for the difference in effectiveness may be that patient navigation is better able to address the social determinants of health. Social determinants of health are the conditions in which people live, work, and play that affect their health. They include things like housing, food insecurity, transportation, and exposure to violence.
Addressing social determinants of health is important because they are a root cause of disparities in health outcomes. By addressing the social determinants of health, patient navigation can help to reduce disparities and improve health outcomes.
Case management services are an important part of the social safety net in the United States. They provide a coordinated and comprehensive approach to helping people with complex needs access the services and support they need to improve their lives.
Case managers work with individuals and families to assess their needs, connect them with appropriate resources, and help them navigate the often-complex social service system. Case management services can make a significant difference in people’s lives, helping them to overcome obstacles and achieve their goals.
Patient navigation services help patients and families manage the complex healthcare system. A patient navigator is a person who can provide guidance and support to patients as they move through the healthcare system. Patient navigators help patients identify and access resources, navigate the healthcare system, and make informed decisions about their care.
Patient navigation services are available to patients of all ages and health conditions. Services are provided by trained patient navigators who work with patients to identify resources and create a plan of care. Patient navigators help patients overcome barriers to care, improve communication with their healthcare team, and make informed decisions about their health.
The Case for Case Management
Because the concepts are so fundamentally dependent upon one another, case management essentially begins as soon as patient navigation services are requested. In fact, the first step in case management often has to do with determining whether further patient management services are required or appropriate. Not everyone undergoing medical treatment will require end-to-end patient navigation services. Patient management models are typically only employed in cases where complex, multi-faceted treatments are required or when a patient lacks the resources or skills necessary to coordinate their own care.
Often, the case management process for patient navigation services extends well beyond the hospital. Patient navigators often help in other ways, such as connecting family members to resources, helping loved ones understand the treatment process, and assisting families in planning and preparing for life after treatment. These personal and holistic aspects of case management can be especially crucial for patient navigators who work in addiction recovery and other behavioral health spaces.
Truly successful patient navigators are the ones who go beyond simply helping patients find a provider and schedule a treatment. Effective patient navigators serve as advocates. In the case of patient navigation for addiction recovery cases, a case manager may even serve as a front-line personal resource for struggling patients or family members. To be a world-class patient navigator and case manager, a provider must be able to help address important quality-of-life issues in addition to coordinating immediate medical needs.
When we say that patient navigation and case management is an integrative and end-to-end process, we mean that it goes beyond a 90-day rehabilitation stay or the end of a chemotherapy regimen. An effective patient navigator needs to set their patients up for lasting success before inpatient treatments have come to an end. Patients must have powerful resources in place to advocate for themselves and see to their own additional needs once the need for day-to-day case management has ended. If a case manager fails to do this, it means that their services have not truly been end-to-end, and they have therefore failed to live up to the definition of patient management we explored above.
A Brief History of Patient Navigation
The patient navigation model emerged as an answer to this crisis in healthcare accessibility. As the medical care landscape in the United States became more complex and specialized, the need for laypeople to have experienced, well-trained assistance navigating the process of seeking and receiving medical care increased. The first programs were designed to increase access to healthcare and promote early diagnosis of serious health issues.
In their 2011 work, Freeman and Rodriguez frame patient navigation as a “community-based service delivery intervention.” That they front-loaded their definition with the term “community-based” speaks to the fact that the most successful outcomes are not usually those that consist of a private relationship between a navigator and a patient. Family members, caregivers, loved ones, medical specialists, and even employers should all be integral pieces of the patient navigation and case management processes. “Community-based” also refers to the fact that navigation services may be targeted towards particular communities (for example, communities with low levels of health insurance coverage).
Patient navigation programs, much like medicine itself, have become more sophisticated and specialized in the ensuing years. Today, the scope of patient navigation goes well beyond connecting low-income communities with cancer care. Patient navigators today are an end-to-end resource, participating in every aspect of care from prevention to detection and diagnosis, to treatment, right on through end-of-life care, and support for survivors.
Patient navigation and case management services can address many common barriers to care, particularly for low-income communities.
These may include:
- Financial issues
- Lack of health insurance (or “under-insurance,” such as budget plans with prohibitive co-pays and deductibles)
- Language barriers or patients who do not speak English who are seeking care in predominantly English-speaking communities
- Communication barriers related to patients being unfamiliar or uncomfortable with medical terminology can occur when someone might feel they don’t know the right words to talk about their condition and become embarrassed to seek care at all.
- Mistrust or misunderstanding of the medical care system
- Emotional barriers, including fear of hospitals due to past experiences
Apogee System Consultants: A Trusted Partner for the Patient Navigation Space
Patient navigation services are crucial for many patients going through complex medical conditions. If you’re operating in the healthcare space, patient navigation and case management are essential components for ensuring every potential patient in your footprint receives access to the services you provide. However, you don’t want to implement this critical service alone.