The Roles, Functions, and Activities of Case Management
Hussein M. Tahan
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
Differentiate among a role, a function, and an activity and how each applies to the case manager.
Understand how the practice of the case manager has changed and expanded over time in the United States.
Identify how and why clients/patients and other health care providers have embraced and accepted case management services.
Explain why the case manager’s role continues to change and be dynamic in practice.
List five various functions case managers perform across the different practice settings across the continuum of health and human services.
IMPORTANT TERMS AND CONCEPTS
Activity
Care Management
Care Manager
Case Management
Case Manager
Context
Domain
Function
Job Description
Practice Setting
Role
Task
Transition of Care
Introduction
A. Roles and functions of case managers are defined by professional organizations/societies (e.g., Case Management Society of America [CMSA], American Nurses Association [ANA], Commission for Case Manager Certification [CCMC], American Case Management Association [ACMA], and National Association of Social Workers [NASW]), based on scientific evidence, literature published by organizations that have implemented case management programs, and educational materials used in training and education of case managers.
B. Roles and functions of case managers are usually written in an organization in the form of job descriptions. However, the research literature that addresses what case managers do tends to report a taxonomy (or a list) of activities and tasks of case management based on which job descriptions can be delineated.
C. The role of the case manager has been implemented in every setting of the health care continuum (preacute, acute, postacute, rehabilitative, and end of life) and is assumed by a variety of professionals from different health disciplines, such as nurses, social workers, rehabilitation counselors, disability specialists, workers’ compensation specialists, pharmacists, and others.
D. The role of the case manager has also been implemented in health care provider organizations for the care of special populations such as clients with multiple chronic illnesses, congenital anomalies, developmentally and mentally disabled, and other vulnerable age groups. Case managers care for these client populations in various settings.
E. There is no standard job description for case managers today in the United States. However, the literature shares common or core aspects of case management practice: clinical/patient care, managerial/leadership, financial/business, quality and safety, and information management.
Descriptions of Key Terms
A. According to the Merriam-Webster Dictionary (Merriam-Webster, 2015), key case manager role-related terms are defined as follows:
Domain—A sphere of knowledge, influence, or activity. In case management, it refers to an area or category of practice and/or knowledge.
Function—Any of a group of related tasks contributing to a larger action; also indicates an official position. In case management, it is the activities a case manager performs in his or her job.
Role—A function or part performed especially in a particular operation or process; the proper function of a person or thing. In case management, it refers to the case manager’s job title or position.
Setting—The scene or locale of any action or event; the time, place, and circumstances in which something occurs or develops. In case management, it refers to the type of agency/organization a case manager works in and what population he or she serves.
B. Tahan and Campagna (2010) defined the terms activity, function, knowledge, and role as described below and used these conceptualizations to guide their research on roles and functions of case managers.
Activity—A concrete and discrete action, task, or behavior that is derived from a function and performed by the person in the role to meet the goals of the role; for example, “list the medications a patient takes while at home.”
Function—A grouping or composite of specific activities within the role. These activities are interrelated and share a common goal, for example, “coordination of care activities.”
Role—A general, conceptual, and abstract term that refers to a set of behaviors and expected results that is associated with one’s position in a social structure. This includes theoretical descriptions that guide one’s expected behaviors. A proxy usually used for the role is the individual’s title, for example, the “case manager.”
Knowledge—A grouping of specific facts, information, skills, and abilities necessary for effective execution of one’s role and related expected behaviors, for example, knowledge of “health care reimbursement methods.”
C. Other case management-related terms are as follows:
Case manager—A health care professional who works with the patient and family as well as the health care team in the coordination of care activities and treatment or case management plan of care. He or she may be engaged in many activities such as patient and family education, counseling, outcomes monitoring, utilization management, and others. The case manager may be a registered nurse, a social worker, a physical therapist, a vocational rehabilitation counselor, or some other licensed health care professional.
Context—The environment or work structure in which a case manager functions, for example, managed care organization or payerbased case manager, hospital, or acute care.
Job description—A document that describes roles and responsibilities, which when appropriately executed produces intended results. It also describes general tasks, responsibilities, and functions; identifies the individual/position to whom the case manager reports; and specifies the required qualifications for the job such as educational background, years of experience, and certification.
Applicability to CMSA’S Standards of Practice
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 among the terms “role,” “function,” and “activity,” before describing what case managers do.
B. The standards of practice advocate for having a clear and contextual understanding of the roles and responsibilities of case managers, which start with delineation what a “role,” “function,” and “activity” mean. The standards define these terms based on the scientific work of Tahan, Huber, and Downey (2006). These definitions continue to apply in today’s case management practice.
C. The case manager, according to the CMSA standards of practice (CMSA, 2010), performs the primary functions of assessment, planning, facilitation, advocacy, monitoring and evaluation which are achieved through collaboration with the client and other health care professionals involved in the client’s care.
D. Key responsibilities of case managers have been identified by nationally recognized professional societies and certifying bodies, usually through case management roles and functions research and evidence. The CMSA standards of practice broadly define the major functions involved in the case management process necessary to achieve desired outcomes.
E. The CMSA standards of practice also clearly caution that successful outcomes cannot be achieved without case managers exhibiting specialized skills and knowledge throughout the case management process and while caring for clients and their support systems. The skills and knowledge base of a case manager may be applied to individual clients, or to groups of clients, such as in disease management or population health models (CMSA, 2010).
F. The CMSA standards of practice highlight key knowledge areas and a set of skills case managers must possess for effective role performance. These are, but should not be limited to those, presented in Box 11-1.
G. The CMSA standards of practice for case management identify a specific set of essential roles and functions of case managers, which can be applied to various care settings across the continuum of health and human services and regardless of professional discipline or background of the case manager. These include, but are not limited to, those presented in Box 11-2.
H. This chapter describes the roles and functions of case managers in greater depth in an effort to expand on those CMSA highlights in its standards of practice and to offer a greater understanding of the complex roles and responsibilities entrusted in case managers.
BOX 11-1 Essential Knowledge Areas and Skills for Case Managers
Knowledge areas
Funding sources
Health care services
Human behavior dynamics
Health care delivery and financing systems
Clinical standards and outcomes
Skills
Positive relationship building
Effective written and verbal communication
Negotiation
Ability to effect change
Ongoing evaluation and critical analysis
Ability to plan and organize effectively
From Case Management Society of America (CMSA). (2010). Standards of practice for case management. Little Rock, AR: CMSA.
BOX 11-2 Roles and Functions of Case Managers
Conducting a comprehensive assessment of the client’s health and psychosocial needs, including health literacy status and deficits.
Development of case management plans of care collaboratively with the client and family or caregiver.
Planning with the client, family and caregiver, the primary care physician or provider, other health care providers, the payer, and the community, to maximize health care responses, quality, and cost-effective outcomes.
Facilitating communication and coordination among members of the health care team, involving the client in the decision-making process in order to minimize fragmentation in the services and maximize efficiency and cost-effectiveness.
Educating the client, the family or caregiver, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, and case management services, so that timely and informed decisions can be made.
Empowering the client to problem-solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes.
Encouraging the appropriate use of health care services and striving to improve quality of care and maintain cost-effectiveness on a case-by-case basis.
Assisting the client in the safe transitioning of care to the next most appropriate level.
Striving to promote client self-advocacy, self-determination, and right to choice including refusal of care.
Advocating for both the client and the payer to facilitate positive outcomes for the client, the health care team, and the payer. However, if a conflict arises, the needs of the client must be the priority.
From Case Management Society of America (CMSA). (2010). Standards of practice for case management. Little Rock, AR: CMSA.
Background
A. Over the past several decades, the field of case management has evolved to meet the changing nature of the health, social, political, and medical care systems. Although the process of case management remains the same, the roles, functions, and venues continue to change and evolve.
The process of case management permeates every aspect of the health and medical care systems, and now, this process is beginning to be used in other industries as well (e.g., legal and business).
This chapter focuses on how the roles and functions of a case manager are executed via the case management process.
B. In 1982, when the U.S. Congress passed the Tax Equity and Fiscal Responsibility Act (TEFRA), it pushed third-party payers to integrate case management services across all lines of health, social, financial, and medical services to control costs and manage limited resources.
C. The case management community established several professional case management associations and organizations that were focused on advancing the practice of case management and its value in the United States. For example:
Case Management Society of America (CMSA)—established in 1990.
National Association of Professional Geriatric Care Managers (NAPGCM)—established in 1985.
Commission for Case Manager Certification (CCMC)—established in 1992 and offers certification in case management.
The American Case Management Association (ACMA) has offered certification in hospital-based case management practice since 2005.
D. In the 1980s, the difference between case and care management was established.
Case management is a term used to refer to the management of acute and rehabilitative health care services. Services are delivered under a medical model, primarily by nurses.
Care management is a term used to refer to the management of longterm health care, legal, and financial services by professionals serving social welfare, aging, and nonprofit care delivery systems. Services are delivered under a psychosocial model.
In the mid-1980s, case and care management entrepreneurs emerged and started independent for-profit companies or private practices that focused on selling case management services as a niche product for the care of a specific population (e.g., the disabled, the work-related severely injured, and most recently the chronically ill).
E. By the 1990s, other health care-related professionals (e.g., physical, occupational, and speech therapists; gerontologists, etc.) began to offer case and care management services on a fee-for-service basis in different practice venues.
F. In 1997, the Foundation for Rehabilitation Education Research (FRER) and NAPGCM cosponsored a case/care management summit to discuss the future of case and care management in the United States.
The summit was held in Chicago in October, 1997. Sixteen professional associations/organizations attended to discuss their vested interest in case/care management and its future in the United States. Participants included the following:
American Association of Occupational Health Nurses
American Nurses Credentialing Center
American Society on Aging
Case Management Society of America
Certification of Disability Management Specialist Commission
Commission for Case Manager Certification
Commission on Rehabilitation Counselor Certification
Foundation for Rehabilitation Education and Research
Health Insurance Association of America
Institute of Case Management
National Academy of Certified Care Managers
National Association of Case Management
National Association of Professional Geriatric Care Managers
National Association of Social Workers
National Guardianship Association
National Guardianship Foundation
The goal of the 1997 Case and Care Management Summit was to “foster cost-efficient, collaborative professional interactions that effectively integrate the medical, psychological, and social elements of each client/provider relationship in a manner that includes the
essential activities of case management in order to provide timely, appropriate and beneficial service delivery to the client. These activities include, but are not limited to, assessment, planning, coordination, implementation, monitoring, education, evaluation, and advocacy. Such integration would encompass, but not be limited to, clients and their families, health care providers, community agencies, legal and financial resources, third-party payers and employers” (Bodie-Gross & Holt, 1998, p. 4).
The 1998 summit also recommended that a second summit be organized to:
Examine and establish minimum standards for qualified case management practitioners and how case managers demonstrate ongoing competency (includes reviewing the different levels of education required for existing credentials and determining the need to standardize the entry level criteria).
Document successful case management outcomes in order to demonstrate the value of the case manager credential.
Develop educational materials to answer basic questions and inform consumers about the qualifications of various providers as well as the types of services care and case managers offer their clients.
Use market research to identify the information needs of specific stakeholders.
Review organizational codes of ethics in order to establish a common code of conduct that all care and case managers could endorse (in addition to their existing codes). Overall code would include, at a minimum, individual scope of practice, requirements for professional disclosure, clarity on conflicts in interests, cultural competency of practitioners, and client confidentiality.
Identify minimum requirements for a qualified practice, develop a mechanism to standardize existing credentials, conduct periodic review of professional development criteria, and determine the need for advanced credentials for care and case managers.
The Second Case and Care Management Summit (1999) was held in Chicago to discuss the topics outlined in the 1998 Summit I Discussion Paper. Participants remained the same, except that the Institute on Case Management did not attend. At the conclusion of this summit, the Coalition for Consumer-Centered Care and Case Management was established. The Coalition was dissolved in 2001 due to a lack of funding.
G. In 1999, Michaels and Cohen (2005) redefined care and case management as follows:
Care management establishes a system of care for a particular condition, across the continuum of care to ensure seamless transition to the right services, right providers, and at the right time and encourages patients and their family/caregiver to manage their own health. Such care is facilitated by a case manager.
Case management is a way of managing unique and high-risk situations often associated with costly acute care and hospital stay. Typically, those who require case management are individuals whose self-care capacity is diminished at a time when their health condition is most complex or even life threatening. Such care is facilitated by a case manager.
H. In the early 2000s, care coordination as a term began to become popular and organizations started to use it somewhat interchangeably with case management, although it is different. Experts argue that care coordination is one important function under the broader umbrella of case management. The National Quality Forum (NQF) in 2006 introduced a definition and framework for care coordination.
NQF defined care coordination as a “function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time” (NQF, 2006).
NQF in its framework identified five key domains: Healthcare “Home”; Proactive Plan of Care and Follow-up; Communication; Information Systems; and Transitions or Handoffs (NQF, 2006).
The definition and framework have been used extensively since then and seem to remain widely adopted as established in 2006.
I. The Patient Protection and Affordable Care Act of 2010 has increased the popularity of case management and the continued need to focus on transitions of care to ultimately enhance patient safety, quality of care, and the experience of care. The Act also has emphasized the impact of value-based purchasing on reimbursement with the shift from volume to value, placing the provider of health care services at financial risk. Case management is a desirable strategy for controlling such financial risk.
Case Management Roles
A. Since the 1980s, the case manager’s role has evolved, transforming itself from being an evaluator of health care services (quality, cost, and safety) to a procurer and negotiator of health, medical, social, legal, and financial services. The role of a case manager has become more sophisticated and active in the care of an individual. Case managers are required to professionally and legally provide state-of-the-art, quality, safety, cost-effective, and ethical services.
B. The changes that have catapulted case managers into the forefront of the health and medical care delivery systems include the following:
Increased complexity of coordinating and financing health/medical care services.
Almost 50 million Americans are uninsured or do not have appropriate health insurance plans and need a case manager to help them navigate and procure needed health/medical care services with limited financial resources.
Due to the economy, many health, medical, and social care agencies and institutions are reducing their list of services because they are deemed to be unprofitable or a “losing asset.”
Many social service agencies have reduced or eliminated services and subsidies (e.g., sliding scales) due to a lack of government funding and grants.
Nonprofit and federally/state-funded social service agencies and organizations are closing down due to a lack of overall funding. This situation is referred to as the “dissolution of the U.S. social service infrastructure.”
The Patient Protection and Affordable Care Act of 2010 has resulted in a decrease in the number of uninsured Americans by over 15 million
individuals. The health insurance plan these individuals have today may not be enough to cover all their health care needs. Case managers are needed to work closely with these newly insured to address their multiple complex needs and assure they receive timely, quality, affordable, and safe care and resources.
C. Most important case management roles as identified by Tahan (2005) and Powell and Tahan (2010) include those described below and listed in Box 11-3. However, case managers may assume other roles as determined by their organizations and employers or the care setting they operate in.
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