CASE MANAGEMENT GOALS IN SCI

1. General
   • Promote patient and customer satisfaction by optimizing patient self-care and providing quality, cost-effective care across the continuum
   • Focus care plan on the patient, and not the system
   • Routinely involve the patient in the development of the care plan
   • Balance patient and family needs with efficacious and cost-effective use of resources
   • Serve as an influential advocate for the patient, by navigating managed care channels, intervening with payers for equipment reimbursements, making sure ADA requirements are present in the workplace, etc. (Hesselgrave, 1997)
   • Routinely monitor, evaluate, and modify the care plan to achieve optimal patient outcomes
   • Evaluate the outcomes of each care plan to ensure that quality care has been delivered and costs have been contained

2. Acute Care Setting
   • Collaborate with all members of the rehabilitation team for effective care delivery and cost-containment (current information on costs of SCI hospitalization and health care living in the U.S. are available from the UAB National Spinal Cord Injury Statistical Center)
   • Focus on expeditious attainment of medical, functional, vocational, and psychosocial outcomes

3. Lifetime Follow-Up Care
   • Restore health and function, manage outcomes, prevent primary and secondary complications, help with adaptation to and education about chronic disability and illness, and maximize activities of daily life
   • Coordinate care and service delivery, continuum management, consultation, and collaboration, within, between, and beyond the acute and rehabilitation programs into the community, to manage reemerging needs throughout the patient's lifetime.  Community resources include addiction, blindness, child care, day care, driving, language interpreters, elder, home modification, meals, employment, protective, religious, support group, and transportation services and programs
   • Focal point of access to the entire health care continuum for SCI patients following acute and postacute rehabilitation
   • Long-term management of medical, functional, and social problems and onset of secondary disabilities related to aging and long-term use of drugs, chronic activities, etc.
   • Achieve optimal medical, functional, and social outcomes within an environment of increasing financial constraints