Case Management

Case management is a process, managed by your health care team, to help you and your family find medical solutions. The case manager is your team coach and advocate. Together, you develop a plan of care to promptly control your illness, injury or situation, and navigate through the maze of medical care progressing toward you medical goal. Generally, patients with complex problems and considerable medical expenses receive case management support. Problems may be one or a combination of medical, social, financial, or mental health.

Who is eligible?

• TRICARE Prime patients
• Participation is voluntary

Diagnoses considered:*

• AIDS
• Bone marrow transplants
• Major burns
• COPD
• Diabetes
• Dual medical & psychiatric diagnosis
• Dual psychiatric & substance abuse diagnosis
• Extended hospitalization
• Head trauma
• High drug costs
• Neonates in NICU
• Neoplasms
• Spinal cord injuries

Other categories considered

• Diagnostic categories
  • Catastrophic illness or injury
  • Chronic or terminal illness
  • Multiple medical problems
• Patient status
  • Functional / physical deterioration
  • Lack of family / social support
• Patient behaviors
  • Noncompliance / resistance to treatment
  • Inability to follow treatment
• General indicators
  • Repeat admissions
  • Unexpected re-admissions
  • Multiple Emergency Department visits / providers

Services last until your case management goals are reached or until you and your case manager decide they are no longer necessary and/or helpful. Case management may be resumed at a later time if needed.

Is there a fee?

Case management is a TRICARE / Prime benefit. There is no additional charge and no billing to your insurance for this service. 

Your specific services may be:

• Advocacy for your needs
• Individualized care plan
• Link to helpful community or other federal support systems
• Liaison with discharge planners should you be admitted
• Clarification of your medical insurance
• Help to self-manage your situation for positive health outcomes
• Scheduled needed services
• Assistance during transitions of care

• Electronic referral: Ask your primary care manager to write a consultation to case management services.  Or your PCM may recommend Case Management services.
• Self-referral: You can self-refer by calling or walking in.

You will work with a registered nurse and/or social worker. Everyone has the same goal-to help you reach optimum health as soon as possible.

Will my Primary Care Manager be informed of these plans and services?

Your PCM is part of the team that helps you make plans and decisions about your health goals. Based on these goals, your case manager develops a plan and continually updates it as you progress. The PCM and you have the final say about your care.

Along the way, we share:

• Your progression according to the case management plan
• Our professional evaluation of family dynamics affecting response to treatment
• Medical insurance coverage as it impacts identified medical needs

• Privacy
• Be cared for with courtesy and respect
• Be told about your health care problems
• Be told how your problems are usually treated and share in the planning
• Be told what you can expect from treatment
• Agree to your treatment
• Refuse any part of your treatment
• Be counseled about what complications could occur if you refuse a treatment
• Be discharged from the case management program at any time you wish

• Treat the case manager with courtesy and respect
• Ask questions about any part of the care you do not understand
• Discuss with the case manager any changes in your condition or how you feel
• Talk to the case manager about other health problems you have had in the past
• Inform the case manager about all medications and remedies you are using
• Follow through on shared goals
• Let the case manager know if you are having problems following any instructions
• Let the case manager know if you decide not to follow the plan of care