Through all the changes in health care and the evolution of new care delivery models, a foundational element continues to be the case management process. Consisting of several iterative or cyclical steps (as opposed to being linear), the case management process is inherently client-centric, as it identifies, implements, and evaluates the effectiveness of care, treatment, and other interventions in pursuit of the individual's goals.
No matter how familiar the case management process may be, even experienced board-certified case managers can benefit from contemplating each step to appreciate how this process encompasses a holistic approach. Anchored in evidence-based practice, the case management process addresses the medical, physical, emotional, financial, psychosocial, behavioral, and other needs of the patient or the "client" receiving case management services, as well as his or her support system (including, but not limited to, family members).
As we contemplate the case management process, we see how certain attitudes and actions-among them advocacy, motivational interviewing, and active listening-enhance cohesion among the nine steps, as identified in the Case Management Body of Knowledge (CMBOK), developed by the Commission for Case Manager Certification. The steps, defined here briefly, are as follows (CMBOK, 2016):
Screening: Review of key information related to an individual's health situation in order to identify the need for health and human services and to determine whether a client or his or her support system would benefit from case management services.
Assessing: Collecting information about the client and his or her support system in order to identify the needs and decide on the best case management services to address client needs.
Stratifying risk: Classification of a client into one of three risk categories-low, moderate, or high-to determine the appropriate level of intervention.
Planning: Establishing specific objectives, goals, and actions necessary to meet a client's needs as identified during the assessment phase.
Implementing-Care coordination: Execution of specific case management and care coordination activities and interventions as necessary for accomplishing the goals set forth in the client's case management plan. The case manager acts as the "hub" of communication among all parties.
Following up: Review, evaluation, monitoring, and reassessment of a client's health condition, needs, ability to conduct self-care, knowledge of the condition, case management plan of care and treatment regimen, and outcomes of the treatments and interventions.
Transitioning: Moving a client across the health and human services continuum or levels of care depending on the person's health condition and the needed services or resources.
Communicating posttransition: Communicating with a client and/or support system after a client transitions from an episode of care.
Evaluating: Measuring results and consequences of the case management plan of care, activities, resources, and services provided to the client and/or the support system.
Far more than a "checklist," the steps in the case management process form a comprehensive, iterative whole. Through advocacy, motivational interviewing, and active listening, case managers support, educate, and empower clients and their support systems to make decisions and access resources in support of their goals.
Advocacy
Case management is well recognized as a means for improving client health, wellness, and autonomy through advocacy, communication, education, identification of service resources, and service facilitation (Commission for Case Manager Certification, 1996/2015, p. 4). For board-certified case managers in particular, advocacy is the heart of case management. As the Code of Professional Conduct for Case Managers states: "Board-Certified Case Managers (CCMs) will serve as advocates for their clients and perform a comprehensive assessment to identify the client's needs; they will identify options and provide choices, when available and appropriate" (Commission for Case Manager Certification, 1996/2015, p. 7). Advocacy is most commonly thought of as providing access to the right care and treatment at the right time. In addition to clinical interventions and a comprehensive care plan, providing access to resources can also happen on a seemingly small, but nonetheless effective, scale.
Consider the hypothetical example of "Martha," who was in her 80s and lived with her husband in their own home. During a follow-up meeting in the medical home where Martha received much of her care, the case manager recommended community resources for Martha's family to investigate. Knowing that clients and their support systems sometimes experience "information overload," and understanding the technology challenge often present in this demographic, the case manager did not simply tell Martha and her family about the resources, but the case manager also provided a document with all the resources and current/pertinent contact information. This practice ensured that Martha and her family received accurate information and had a physical reminder for follow-up. Even the subtlest interventions, in the name of advocacy, support and empower the client, leading to more consistently positive outcomes and autonomy.
Motivational Interviewing
Building trust is crucial at every phase of the case management process. An important way to foster trust and support open, honest communication is through motivational interviewing. This is a highly effective technique for gathering important information and obtaining insights about every aspect of a client's situation-social, financial, emotional, and health. Drawing upon "a supportive and empathic counseling style of communication," motivational interviewing "helps clients move toward a course of successful and desirable change" (Tahan & Sminkey, 2012, p. 163). Motivational interviewing also helps the case manager work closely with the client/support system to set goals and gauge progress.
Motivational interviewing is vitally important at assessment and remains crucial throughout the process, such as during the follow-up phase as the case manager gathers new information and decides whether it is necessary to add to, discontinue, or modify the case management plan as the needs of the client/support system change (CMBOK, 2016). Through motivational interviewing, the client is encouraged to "tell an accurate and complete story," which "makes a big difference in the case manager's ability to develop an appropriate case management plan of care, achieve expected care goals, and meet the client/support system's interests and needs" (Tahan & Sminkey, 2012, p. 165).
For example, "David" was severely injured in a motorcycle accident and underwent a series of surgeries and an extended period of rehabilitation. Over many months of working together, his case manager utilized motivational interviewing to help David identify his goals and what he needed to achieve them. Although his ultimate goal was achieving maximum medical improvement and being able to walk unassisted, David had to go through a long period of recovery first.
To keep him engaged and motivated, he and his case manager set short-term goals that served as milestones on his road to recovery. Motivational interviewing not only kept the focus on David's near-term and long-term goals but also ensured that his concerns, questions, fears, and expectations were voiced and acknowledged.
Listening
Hand in hand with motivational interviewing is the key communication skill of listening. By summarizing and repeating back what the person has said, the active listener demonstrates attentiveness. Listening at the assessment phase, for example, helps case managers gather information from multiple sources, especially from clients and/or support systems. Listening also helps identify social issues that might affect care, such as fluency in English or the need for a translator; ability to understand medical instructions; cultural issues the case manager needs to be aware of; and other psychosocial issues.
Later on in the process, listening remains just as important-even when the case manager has been working with the client and support system for some time. No matter how familiar the case manager is with the case, assumptions cannot be made about what the client or support system may or "should" need. For example, "Virginia" was the sole caregiver of her elderly father. While reviewing the case file before their next meeting, the case manager wondered whether Virginia might request a respite. If she did, the case manager could suggest some resources to help make that happen.
The case manager, though, did not make that assumption. Rather, the case manager listened attentively to Virginia who never mentioned wanting a respite; her only questions were about how to obtain safety equipment in the home. By listening first, the case manager was able to stay true to the case management process of identifying the individual's goals and providing options and education to empower decision making.
An Iterative Process
The case management process provides the context in which professional case managers provide access to care, treatment, and other resources across the health and human services spectrum (CMBOK, 2016). Professional case managers continuously help clients and/or their support systems to evaluate and understand available care options and determine what is best to meet their needs. Through each step in this iterative process, professional case managers draw on key attitudes and approaches such as advocacy, motivational interviewing, and active listening to enhance their professionalism and showcase their competence and expertise in case management, especially the crucial care coordination role.
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