Executive Summary
Standards of practice tools are excellent to review periodically, experts say. These provide specific guidance for case managers who work in any setting.
• Client engagement is important because CMs need to know what clients identify as issues.
• CMs need to document an agreement among the client, family, or caregivers and address the patient’s health issues.
• Case managers assess and document the clients’ responses to the plan of care.
As healthcare transforms in the United States, case management is more in demand than ever.1
This means that current CM professionals need to make sure they represent the field well, following standards of practice such as those published by the Case Management Society of America (CMSA), the National Association of Social Workers (NASW), and the American Nurses Credentialing Center (ANCC).
For example, the CMSA standards of practice provide specific guidance to follow no matter where you practice, notes Judy Woodward, MSN, RN, state quality improvement director at the Tennessee Department of Health in Nashville. Woodward published a recent paper on case management.1
Woodward, who has taught and worked with case managers, offers these suggestions for how CMs can make sure they adhere to standards of practice, as described below:
• Client selection process. Client engagement is part of a case manager’s selection and assessment, Woodward says.
The CMSA standards of practice list the client selection process first, saying it includes documentation of consistent use of the selection process within the individual organization’s policies and procedures.2
“If you cannot engage the patient, you’re not going to get anywhere in terms of helping them because they have to be involved in their decision-making,” she explains.
Motivational interviewing is one common practice, she adds.
NASW’s standards say that clients should be engaged in the case management process and participate in shared decision-making. Assessment is an ongoing activity and not a one-time event.3
“You need to know what the client identifies as an issue,” Woodward says. “They may have something that is much more pressing that has to be taken care of; there might be some personal issue within the family, and until that’s resolved, they can’t move on.”
CMs also need to plan with clients in a way that is not intrusive. “Case managers know their patients, their situations, and they know what’s important to them and know what they need,” she says.
While there are many other aspects of case management, engaging with patients should be a top priority, Woodward adds.
“I would say the most important magic of case management centers on patient engagement,” she says.
• Client assessment. Assessment is the first component in the framework for nursing case management, according to ANCC standards.4
ANCC states that nurse case managers need to assess health and psychosocial needs — including health literacy — of patients. They also need to develop a case management plan collaboratively with all stakeholders.4
Case managers with a nursing background bring a tremendous amount of assessment skills to the table, Woodward says.
“The most important aspect of assessment involves listening to what nurses call their ‘third ear,’” she explains. “You hear what they’re saying, but what else are you hearing?”
For instance, when a CM visits a patient at home, the CM makes observations of the home environment and potential obstacles and motivators to better health and medical treatment adherence. “If their walls are full of framed photos of their family, then it’s clear the family is their motivator,” Woodward says.
“Nurses are historically very adept at taking everything into account when they assess a patient,” she adds. “Many times, our patients can’t verbalize what they need and want, so it takes a very skilled provider to help them walk through that.”
• Problem or opportunity identification. This standard gets to the heart of case management. CMs need to document an agreement among the client, family, or caregiver, and other providers about the problem or opportunity that is identified.
For example, a diabetic patient has been rehospitalized for an exacerbation of the disease. “You start identifying the problem by saying, ‘Tell me about what diabetes is like for you,’” Woodward suggests.
“If the patient is telling you, ‘I don’t even have time to think about my diabetes because my adult son is living with me and he has schizophrenia and doesn’t have insurance, and I can’t manage him,’ then the diabetes will have to wait,” Woodward explains.
The case manager has identified an urgent problem that has to be resolved in the patient’s life before the patient can focus on diabetes medication adherence.
Case managers can start the identification process by walking into the room with the patient’s clinical data, but their goal should be to discover what the patient truly needs, she adds.
• Standard planning. Case managers need to identify immediate, short-term, long-term, and ongoing needs. This is another example of how the best way to meet the standard is through developing a trusting relationship with the patient, Woodward says.
“We talk about that in nursing all the time: When a patient is engaged and you have a good relationship with the patient, then that’s when the planning can begin,” she says.
“If you were to walk in and tell someone, ‘Here’s what you need to do,’ then the person might listen patiently and might be a little involved,” Woodward explains.
But the patient will be far more likely to adhere to the plan if the case manager has engaged them effectively, she adds.
“Case managers can map out a period of time to develop that trusting relationship and to monitor whether the patient went to the doctor’s appointment and made their medication changes,” Woodward says. “But you’ve got to get the patient on board.”
• Monitoring. The NASW standards include service planning, implementation, and monitoring. They advise social work case managers to collaborate with clients to plan, implement, monitor, and amend individualized services that promote clients’ strengths, advance their well-being, and help them achieve their goals.3
Case managers assess and document client’s response to the plan of care. For instance, they can keep track of how clients are doing via phone calls, Woodward says.
The goal is proactive monitoring responses to care and treatment and recommending changes to the plan of care to improve outcomes, the ANCC guidelines say.4
“You and your patient develop a plan,” Woodward says. “He says, ‘I’ll keep my doctor’s appointments, check blood sugar every day.’”
The case manager checks back the following month and sees that the patient missed a doctor’s appointment and only checked his blood sugar once, she says. “You ask, ‘What do you think is preventing you from doing it?’ Does the person have a family crisis, transportation problems, work schedule interference? This is a critical part of monitoring outcomes.”
• Outcomes. One of the core functions of social work and nurse case management is evaluation of outcomes, according to the NASW, CMSA, and ANCC.2,3,4
The goal of this standard in all three guidelines is to maximize the client’s health, wellness, safety, adaptation, and self-care through quality management, client satisfaction, and cost-efficiency.
Case managers might talk with a client and note that since they’ve been taking care of themselves, they have not been in the hospital and have not had to take additional insulin and have lost five pounds, Woodward says.
“You provide reinforcement and stress that it was their plan, and they succeeded with their goal, and look at what they did for their health,” Woodward says. “It really is a process.”
• Termination of CM services. CMs talk with clients about how case management services can be terminated.
The length of case management services depends on the circumstances of the patient’s injury or illness, Woodward notes.
“If someone has had a motor vehicle accident, and case management can be completed within three months, then that’s okay,” she explains. “With disease state management, there may not be termination.”
The goal always is for clients to manage their own care, and so case managers continually are teaching them additional skills, Woodward adds.
• Facilitation, coordination, and collaboration. It’s the CM’s job to facilitate, coordinate, and collaborate with clients and other stakeholders.
It’s an essential skill that case managers use to unite members of the healthcare team and others who help design a plan of care for the patient.3
“This is something where case management will be at the forefront because of the Affordable Care Act and trying to save healthcare costs,” Woodward says. “There will be massive collaboration between providers and agencies.”
Eventually, there might be a case manager hired or contracting with every practice, she adds.
“This is an opportunity for free-standing agencies to work with case managers,” Woodward says. “We’re moving away from the doctor telling a patient, ‘Take this medicine.’”
Case managers are the ones who will make sure medication adherence happens and doctors’ appointments are coordinated. They help patients navigate the system, and they help motivate patients to improve their health, Woodward says.
• Qualifications for CMs. Case managers have to maintain licensure or certification and should have appropriate educational credentials.2
Social work case managers should possess a bachelor’s or advanced degree in social work from an accredited program and should comply with the licensing and certification requirements of the state.3
• Legal. CMs need to adhere to all laws, employer policies, and maintain client privacy and confidentiality.2
“Whenever you’re dealing with families, you have to be careful confidences,” Woodward notes.
Organizations’ policies and procedures should reflect all legal concerns.3
• Ethics. Case managers should follow the five basic ethical principles, including beneficence, non-malfeasance, autonomy, justice, and fidelity.2
“You have to be ethical,” Woodward says.
And it’s up to case managers to adhere to a code of professional conduct or ethics.4
• Advocacy. It’s the case manager’s role to advocate for patients at all levels.
“Case managers advocate for their patients, and they need to have cultural competency,” Woodward adds.
• Cultural competency. The CM role is to be aware of and responsive to cultural and demographic diversity of the population and specific client profiles.2
CM services are provided to all individuals regardless of culture, age, or ability to pay.4
Social work CMs are advised to recognize that culture varies within families and cultural groups.3
“It will be impossible to be effective with a patient and planning the patient’s care if you don’t understand who the patient is and where the patient comes from,” Woodward says.
Understanding different cultures does not refer only to people in international settings. There can be different cultures within various regions of the U.S., she adds.
• Resource management and stewardship. “This standard is huge,” Woodward notes. “If you give case managers a toothpick, they’ll figure out how to do things in a really creative and ingenious way.”
The standard asks that CMs integrate factors related to quality, safety, access, and cost effectiveness in assessing, monitoring, and evaluating resources for the client’s care.2
Integrated case management streamlines processes and improves resource management.4
Offering options to patients even in the case of limited resources is a key part of the social work case manager’s mission.3
“Make the most of what you have,” Woodward says. “No matter who the patient is, you won’t have enough resources for what the patient needs, so you have to be creative in locating the resources they need.”
• Research. CMs need to keep up with the most current research findings and apply them, as appropriate.2
They also can participate in qualitative and quantitative social work research to strengthen the evidence base for case management.3
As case management evolves, CMs should use research to refine and validate the practice.4
References
- Woodward J, Rice E. Case management. Nurs Clin North Am. 2015;50(1):109-121.
- Frater J, Leonard M. Standards of practice for case management. Published by the Case Management Society of America (CMSA); 2010. http://www.cmsa.org/portals/0/pdf/memberonly/standardsofpractice.pdf.
- Anastas JW, Clark, EJ, Aufderhaar L, et al. NASW standards for social work case management. Published in 2013 by the National Association of Social Workers (NASW) at https://www.socialworkers.org/practice/naswstandards/CaseManagementStandards2013.pdf.
- Leonard M, Miller E. Nursing case management review manual, 4th Edition. Published by the American Nursing Credentialing Center (ANCC); December, 2012. http://www.nursecredentialing.org/CaseMgmtManual.aspx.
Standards of practice tools are excellent to review periodically, experts say. These provide specific guidance for case managers who work in any setting.
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