WHAT IS ACTIVE CASE MANAGEMENT?
8 December 2016
Our case managers focus on providing support to a customer who is faced with a long hospital stay, a serious illness, or needs help coordinating a major medical intervention or repatriation. It is in these complex situations that we make a difference, for the patient and our clients' plans.
Once notified of a case, our case managers step in to enhance the patients' comfort and wellbeing, while keeping the costs under control by lowering out-of-pocket expenses which ensures the long-term viability of medical plans. To our case managers, it is more than just another case: they keep close contact with the patient throughout the hospitalisation or treatment, with personal visits or calls to see how they are coping. Our case managers coordinate access to care, explore service/treatment alternatives, monitor progress, assist with discharge planning and follow-up and help ensure existing benefits are used effectively.
This personal approach and follow-up requires proximity to our clients. Our Communication Officers are close to where large groups of customers are located. In addition to performing local case management they pay regular visits to the local offices of IGOs and NGOs to give presentations or conduct personal interviews so customers can receive one-on-one practical or health-related advice. They act as a focal point and are our eyes and ears in the field.
A day in the life of Hellen Gatwiri Kiburi, Case manager in Nairobi
Case manager and trained nurse Hellen Gatwiri Kiburi is based in one of our clients' offices in Nairobi, Kenya. She coordinates patient care from admission to discharge and also handles the patient's aftercare if rehabilitation is needed. Follow-up of the case through close contact with all involved is important, which is why Hellen stays in touch with family members, providers, treating physicians, our office based case managers and the client.
We followed Hellen for a day while she talked about her responsibilities…
Starting my day with a full mailbox
First of all, I log on and start working on my inbox. My inbox queue is very important as it may hold information requested from my colleagues in order to send Guarantees of payment (GOPs).
Our GOPs must be sent within 24 hours of admission to avoid discharge delays, or immediately if here is an emergency, such as an evacuation. I also receive a lot of e-mail queries from customers and I try to respond to them within 24 hours, so I clear my inbox every day.
While working through my e-mails, I receive a call from a customer to inform me that his spouse was very ill and an ambulance was required. I put everything on hold and coordinate the ambulance pickup, inform the hospital of the upcoming case and tell them to bill Cigna. I contact a doctor to let him know that the patient is on her way. Then I also inform our Antwerp office of this case so my colleagues can send an urgent GOP.
As clients, doctors and hospitals in Kenya know me personally, they usually do not call our office in Belgium, they call my mobile number for questions, complaints, clarifications etc. Some calls, such as this one, require immediate attention and a hands-on approach.
A quick break
I close the office and go to the staff cafeteria for a quick lunch.
Sorting out the administration
I drive through Nairobi to the Sarit Centre where we have a drop-off point for invoices from hospitals, doctors and clients. I open this box at least every two days, put all the invoices/claims together and send them to our claims offices for processing.
A tour through the city to visit patients and providers
I drive to the Aga Khan Hospital to see admitted patients with specific issues. For example, one of our patients has been staying in the hospital too long, so we want to know what is going on and whether there is anything we can do for him. I meet with the treating doctor and find out that the patient will be ready for discharge soon.
For hospital admissions we ask for a written medical report with justification. Sometimes it takes so long to receive this report that I go to the hospital to personally follow up on this. From time to time, I need to sit down with the accounts departments of the respective providers to settle our payments, or sort out pending payment issues at a doctor's office.
Some afternoons, instead of visiting hospitals, I go and see clients or have individual or group meetings at their offices.
At the end of the day I call our Customer Services offices to brief my colleagues on my patients' cases. As I return home to my family, they take over any critical cases, calling me at home when they need urgent advice or assistance.