Role of disability-case manager for chronic diseases: using the ICF as a practical background

To report on the case manager's activity in a hospital setting as a supporting professional for families that need to deal with different services and professionals to get answers on their health and psychosocial needs.

A qualitative analysis and interpretation based on the case manager observations and ICF checklist evaluation with medical and rehabilitation professionals were employed.

The case study presented aimed to show one of the most typical interventions of the case manager: the creation of a network around a person with complex and multifaceted needs, where this network does not exist. Case manager bridged the gap between health and social services, specifically organising home-based rehabilitation and helping to find appropriate assistive devices.

This case study showed that the case manager's role is fundamental to support patients and their families in relating to the different services and professionals they need, and illustrated one of the most typical interventions of the case manager: the creation of a network around a person with complex and multifaceted needs, where this network does not exist.