A. Case management is an interdisciplinary practice that focuses on the coordination of the care activities and interventions and the allocation of resources required by a client/patient during an acute or nonacute episode of illness or encounter with a health care provider.

B. A case manager manages, facilitates, coordinates, and evaluates the necessary care activities, interventions, and treatments, applying an approach to care delivery that is called the case management process.

C. The case manager also manages communication among the varied care providers and other essential parties (or stakeholders) internal and external to the health care organization.

D. The case manager communicates with the client, family, and/or caregiver on an ongoing basis to assure active engagement in decision making about care options and that care meets the client’s interests, goals, and preferences.

E. The case management process focuses on the identification of clients/patients who would benefit from case management services and the activities of assessment, problem identification, care planning, care delivery, advocacy, monitoring, and evaluation of the care provided, specifically for its relevance to the needs of the patient/family and for the health care team’s ability to meet the desired outcomes and established goals.

F. Each client/patient is unique, and the case management process takes into consideration the individual needs of the patient, family, and caregiver. This is not only limited to the patients’ medical condition and treatment; rather, it includes their financial and psychosocial state as well as their culture, values, and belief system.

G. Each case manager has her or his own unique style of case management based on one’s own experience, education, skills, knowledge, ability, competence, creativity, clinical specialization (e.g., critical care, organ transplantation, rehabilitation, home care), professional discipline (e.g., nursing, social work, rehabilitation counselors, workers’ compensation specialists), professional networks, and advanced credentials (e.g., certification in case management or clinical specialty).

H. The case management process is a set of steps applied by case managers in their approach to patient care management. It is similar to the nursing process or problem-solving approaches (and other processes used by other disciplines such as social work and medicine).

I. The case management process has been applied in the care of a select group of clients/patients based on certain criteria determined by the health care organization or provider and dependent on the care setting. These criteria are the necessary factors that indicate the patient’s need for case management services.

J. Some activities of the case management process may vary significantly based on the case management setting (preventive, preacute, acute, postacute or payer-based/managed care, ambulatory, hospital, community, home, skilled facilities, and so on) and the population served (pediatric, geriatric, behavioral health, well individuals, and so on).

K. Through the case management process, case managers eliminate fragmentation and/or duplication in care delivery. They also maintain open and timely communication with all parties involved in care in an effort to ensure continuity, safety, quality, timely, and cost-effective outcomes.

L. The case management plan designed by the case manager in collaboration with the client/patient, family, and other health care providers identifies client’s immediate, short-term, and ongoing needs, as well as where and how these care needs can be met.

A. Advocacy—“The act of recommending, pleading the cause of another, to speak or write in favor of” (CMSA, 2010, p. 24). Case managers demonstrate advocacy when they are acting on behalf of those who are not able to speak for or represent themselves and when defending others and acting in their best interest.

B. Advocate—A person or group involved in activities of advocacy is called an advocate.

C. Assessment—The collection of “in-depth information about a client’s situation and functioning to identify individual needs and in order to develop a comprehensive case management plan that will address those needs. In addition to direct client contact, information should be gathered from other relevant sources (patient/client, professional caregivers, nonprofessional caregivers, employers, health records, educational/military records, etc.)” (CCMC, 2015, p. 7). CMSA describes assessment as a “systematic process of data collection and analysis involving multiple elements and sources” (CMSA, 2010, p. 24).

D. Collaboration—Working together with the client/family, other health care providers and agents who are both internal and external to the health care organization for the purpose of achieving consensus on the client’s care goals, case management plan and to maximize the achievement of desired care outcomes.

E. Continuum of a concept involving an integrated system of care that guides and tracks clients/patients over time through a comprehensive array of health services across all levels of intensity of care. It reflects care provided over time in various settings, programs or services and spanning the illness-wellness continuum with varying degrees of complexity, acuity and intensity depending on the care setting. It refers to the different settings and types of health care services an individual may access for the purpose of wellness, prevention or treatment of a disease. Case managers use the continuum of care while engaged in the case management process to match the ongoing needs of their clients with the appropriate level and type of health, medical, financial, legal, and psychosocial care for services within a setting or across multiple settings or providers.

F. Coordination—“Organizing, securing, integrating, modifying, and documenting the resources necessary to accomplish the goals set forth in the case management plan” (CCMC, 2015, p. 7).

G. Discharge planning—The process of assessing the patient’s needs of care after discharge from a health care facility or a care encounter and ensuring that the necessary services are in place before discharge. This process ensures a patient’s timely, appropriate, and safe discharge to the next level of care or setting, including appropriate use of resources necessary for ongoing care.

H. Evaluation—“Determining and documenting the case management plan’s effectiveness in reaching desired outcomes and goals. This might lead to a modification or change in the case management plan in its entirety or in any of its component parts” (CCMC, 2015, p. 8).
This activity is repeated at appropriate intervals and is adjusted or changed as necessary based on the plan and the client’s condition.

I. Facilitation—An activity assumed by the case manager to promote communication among the client/family and the health care team members including the insurer. Facilitation also focuses on collaboration among all parties to achieve the case management goals and to ensure informed decisions by the client and that the necessary interventions are happening as intended.

J. Implementation—“Executing and documenting specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan” (CCMC, 2015, p. 7). Implementation of the case management plan also means linking the patient’s assessed needs with private and community services, filling the gaps in care and services, avoiding duplication of services, and obtaining agreement on the plan of care from the patient and his or her support systems. The main goal in these activities is maximizing the safety and total well-being of the patient.

K. Intervention—Planned strategies and activities that are employed to modify or manage a maladaptive behavior or state of being (e.g., health condition) and facilitate improvement, resolution, growth, or change. Intervention is also analogous to the medical term treatment. Intervention may include activities such as advocacy, medications management, health instructions, physical therapy, or speech-language therapy.

L. Monitoring—Reviewing and “gathering sufficient information from all relevant sources and its documentation regarding the case management plan, and its activities and/or services to enable the case manager to determine the plan’s effectiveness” (CCMC, 2015, p. 7).

M. Outcomes—The measurable results of a process or action such as adherence to health regimen. Used to assess the effectiveness of case management interventions to determine their impact and consequences as they relate to the client (e.g., clinical, financial, variance, quality/quality of life, client satisfaction) (CCMC, 2015).

N. Planning—“Determining and documenting specific [case management] objectives, goals, and actions designed to meet the client’s needs as identified through the assessment process… [usually] action-oriented and time specific” (CCMC, 2015, p. 7).

O. Problem identification—Use of objective data gathered through careful assessment and examination of a client’s situation to articulate concerns and areas of interest that require special attention. This process allows the case manager to decide on the focus of case management services and implementation of necessary interventions reflecting practice patterns and trends wherein client outcomes can be positively influenced.

A. The Case Management Society of America (CMSA) describes the roles, functions, and activities of case managers in its standards of practice for case management (CMSA, 2010). The standards emphasize the importance of differentiating between the terms “role,” “function,” and “activity,” before describing what case managers do.

B. The case management process is carried out within the ethical and legal realm of a case manager’s scope of practice, using critical thinking and evidence-based knowledge. The overarching themes in the case management process include the tasks described below.

C. Case management is neither linear nor a one-way exercise. For example, the assessment responsibilities will occur at all points in the process, and functions such as facilitation, coordination, and collaboration will occur throughout the client’s health care encounter.

D. Primary steps in the case management process according to Powell and Tahan (2008) include those described in Box 12-1.

A. The case management process is a systematic approach to patient care delivery and management.

B. Step 1: Client identification/selection—Focuses on identifying clients who would benefit from case management services.