They may not be checking your vitals, but case managers are a vital part of patient care, guiding patients and their caregivers every step of the way through their stay in inpatient rehabilitation and beyond.

The work of a case manager, a key part of the interdisciplinary care team at an inpatient rehabilitation hospital, begins soon after a patient arrives at an Encompass Health rehabilitation hospital and continues after they have been discharged. Below, Dina Walker, Encompass Health’s national director of case management, shares more information on the many roles of case managers in inpatient rehabilitation.

A jack-of-all-trades

Case managers at Encompass Health inpatient rehabilitation hospitals are different from those in other care settings.

For example, in an acute-care setting, “case managers” may no longer exist. Often, the traditional responsibilities of a case manager have been redistributed and divided into more specific roles, such as a utilization review nurse and discharge planner. A variety of clinicians, including nurses and social workers, fill these specific roles. 

In an inpatient rehabilitation hospital, a single case manager performs all case management functions for a patient, managing the entirety of the patient’s “case.”

“Case management, especially in an inpatient rehabilitation hospital is an advanced practice,” Walker said. “Our case managers come from a variety of healthcare-related settings and backgrounds. They come to us with good core knowledge and we layer on top of that more well-rounded experience and inpatient rehabilitation expertise.”

Case managers at Encompass Health not only need to understand the inpatient rehabilitation setting, Walker said, but also must be familiar with all other levels of care. 

“Case managers should understand all levels of post-acute care so they can help the care team determine the next appropriate care setting when the patient is nearing discharge from the inpatient rehabilitation hospital,” she said. “We’re constantly weighing priorities for our patients, making sure the patient is in the right care setting at the right time for the right reason.”

In addition, case managers are well versed in insurance coverage, benefits and payment models. The case manager must have the knowledge and experience to balance financial considerations with patient advocacy. 

A moderator and negotiator 

An interdisciplinary approach to patient care means the case manager is coordinating the many care team members involved in that patient’s care. While all clinicians are focused on delivering exceptional patient care, case managers are able to look at the big picture of a patient’s unique plan, making sure it meets that patient’s needs, treatment preferences, and sets them up to successfully achieve their goals.

“We’re able to facilitate communication across all the key care disciplines to deliver patient-centered care; caring for the whole person, including their families and their support systems,” Walker said.

A detective

By and large, Walker said, case manages should love solving puzzles, as investigating all key details of a patient’s care is a significant part of the job.

“Case managers take tidbits of information from multiple sources and tie it into the bigger, patient-centric picture,” she said. “They also assess what might be missing from the care plan and they have to know the right questions to ask.”

An advocate

Above all, a case manager is a passionate, relentless patient advocate—and that advocacy doesn’t stop once a patient leaves the hospital. Case managers coordinate care and services with community agencies and implement a transition plan to help keep patients safe and progressing after discharge.

“You have to be passionate about assisting patients in achieving their health-related goals and committed to fulfilling your role to the best of your ability in helping them get better and improve their health,” Walker said.

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