Case Management & Health Plan Perspective

Case Management January 24 by RWW

“A few of us felt very strongly that their services were needed,” she explains. “Our stroke and TBI cases needed more intensive services than an acute care stay could provide, and I personally believe that patients adapt way better in the home and community setting than in a hospital.” In addition, she says she is impressed with the way Rehab Without Walls listens to a patient’s “hopes and dreams” when planning care.

She cites the case of a woman—a seamstress who also loved to sing in her church choir—who sustained a stroke. “I love that the Rehab Without Walls physical therapist (PT) was determined to sit her at her sewing machine. In the early weeks, maybe all she could do was sew a straight line, but she was doing it. The PT also encouraged her to sing around the house. Those are the little things that give a person a sense of still being vibrant and whole. A traditional PT wouldn’t focus on that—even though it addresses movement and functionality—and I think it works with motivation, as well as easing anxiety and fears.” Some of the other reasons she sees Rehab Without Walls as an appropriate option within the managed care continuum:

Home and Community Setting

“Most patients are tired of being in an inpatient rehab setting and want to make a go of it at home. They tend to do better there, too, so we try to get patients out of the hospital quickly and matched with the appropriate team. We determined that we would use the acute rehabilitation benefit for Rehab Without Walls because that is essentially what they provide—only in the home and community setting.”

Individualized Care

“As a case management nurse in the insurance industry, I really try hard to tailor care to the individual, which is one of the joys of working with Rehab Without Walls. We collaborate as a team to provide what the patient needs.”

Specific Neurorehabilitation Expertise

“I try to get Rehab Without Walls involved at the time when the brain is most plastic and most able to heal. If you have a dedicated neurorehab team, it can make all the difference in the world. I’ve seen what a huge difference 25 to 30 hours a week can make for the patient.”

Seamless Communication

“Phone calls, emails, conference calls, team meetings, close patient monitoring—Rehab Without Walls is great about communicating. They try to make it as seamless as possible, and when problems arise or adjustments need to be made, they perform them quickly and communicate right away.”

Cost Savings

“Rehab Without Walls is able to provide savings in several ways. I see a cost savings if I am able to move a patient out of intensive inpatient rehabilitation and into the home as well as when a patient can reach maximum functionality and independence in the home before moving into an outpatient setting.”

Ability to deal with challenges

“When a young person has significant physical deficits or a person’s personality changes due to a TBI, they often do not understand how much things have changed in their life and how they need to address them. Rehab Without Walls works with this beautifully, helping them make a plan, determine goals and set realistic expectations. Then they ensure that everyone on the team reinforces them.”