By Pam Rafols and Faiza Hendricks

The week of 9th to 15th October is National Case Management Week and the National Case Management Association of South Africa (CMASA) will be hosting a number of events around the country to highlight the important role Case Managers play.

Hospital Case Managers are professionals in the hospital setting who ensure that patients are admitted and transitioned to the appropriate level of care, have an effective plan of care and are receiving prescribed treatment, and have an advocate for services and plans needed during and after their stay.

As the delivery of healthcare system changes with advances in technology, legislation and the fact that medical aid funding principles are constantly changing, the practice of hospital case management evolved. Each hospital has its own structure and deliverables and to this end it will determine the role and function of its case manager.

Rondebosch Medical Centre employs 2 case managers who are qualified nurses with extensive training in General Nursing, Specialized Nursing as well a reputable tract record in the Managed Healthcare industry. In addition they have experience in Clinical coding which is integral to the healthcare industry, in both the public and private sectors. They assess health records to abstract diagnosis and procedures and accurately assign International Statistical Classification of Diseases and related health problems (ICD) and Procedure Codes .This speaks to the written description of a medical diagnosis into a coded format. It is important for members of a Medical Aid fund to realize this, since it is paramount to their clinical treatment being funded.
As case managers it is important to understand hospital processes and the importance of cost effective decisions .The private health sector in South Africa is under immense scrutiny and this has increased pressure to deliver cost-effective, quality healthcare. With experienced Case managers on board, patients admitted to RMC, can be assured that their Medical benefits will be utilized optimally.

Rondebosch Medical Centre is a newly established private institution of excellence, whose vision is to provide the highest level of private healthcare at an affordable cost, so as to ensure greater accessibility to all. At RMC we pride ourselves on the fact that in collaboration with Medical practitioners, Nursing staff and Administrative staff, the case managers display strong customer focus and a heightened sense of patient advocacy.

The admission process for all patients admitted to hospital can be made smoother and easier should patients comply with certain basic requirements such as producing proof of identity and medical aid details upon admission ,In the case of pre booked admissions , a valid authorization number is required. However in a medical emergency, hospital administrative staff is only too willing to assist with obtaining an authorization in the presence of the necessary documents.

Adhering to ethical and legal standards, case managers ensure that patient confidentiality is maintained at all cost .Clinical information is only shared with service providers and medical aids which is responsible for funding of the patient’s treatment. Yes …often our case managers are described as “medical detectives”.

Asking a hospital case manager what her greatest challenge is, the answer would probably be the “pitfalls” of medical aids .These include challenges related to Designated Service Providers (DSP), Co–payments , Non covered Services , Waiting periods and Limited Benefits . We find a significant lack of knowledge when it comes to these pitfalls. Our advice to members of a medical aid is to familiarize themselves with their benefit structure as well as the challenges mentioned.