Clinical Case Manager
St Mary’s Hospital currently has two case managers in post Dei Moran and Shirley Long that support the following acute services by linking with community services: Cappagh Hospital, Connolly Hospital, Fairview Community Unit, Mater Misericordiae University Hospital.
The Clinical Case Manager role involves organising and coordinating care of identified individuals between community and acute services. The clinical case manager acts as a point of contact for these individuals and their families and is responsive, flexible and adaptable to community services in order to avoid unnecessary admission to acute care services.
The clinical case manager utilises a number of key resources and stakeholders to navigate identified individuals through the healthcare system effectively and efficiently. The clinical case manager incorporating a MDT approach focuses on and develops a longer term care plan for these individuals to anticipate future care needs. Case management to not a stringent model of care and there is no all-encompassing definition however, there is a series of core components when using a case management approach.
These include: (1) Case finding, (2) Needs assessment, (3) Care planning, (4) Care coordination. Individuals identified for case management must be over the age of 65years, have complex medical/social issues, be medically frail, multiple-morbidity, Under the Medical Care of a Geriatrician and reside in Catchment Area 9.
The clinical case manager links the community and acute services and assists the older person through their care journey rather than focuses on a single episode of care. The clinical case manager can assist the older person in conjunction with their primary care givers (PHN, GP, Family, Care Agency) to remain in their home environment as long as possible by incorporating any number of the services to sustain the individual in the community. When an older person’s care needs change or develop steps can be taken to facilitate the next stage in their care journey to be advanced and progressed from home preventing unnecessary length of stay in acute care environments.