The case management knowledge framework consists of what case managers need to know (knowledge, skills, and competencies) to effectively care for clients and their support systems. It includes two main elements: Show
These elements are applicable in any care or practice setting and for the various healthcare professionals who assume the case manager’s role and/or those directly or indirectly involved in the field. Definition of Case ManagementThere is no one standardized or nationally recognized or even widely accepted definition of case management. An Internet search for the definition of the term case management will result in thousands of references. Such results are confusing for case managers and others who are interested in case management practice. You may be unable to discern which definition is most credible or relevant. Despite the large search outcome, experts would agree that there are no more than 20 or so definitions of case management considered appropriate. These definitions are available in peer-reviewed professional case management literature or on Web sites and in other formal documents of case management (or case management-related) organizations, societies, and government or nongovernment
agencies. The Case Management Knowledge Framework View larger image So that you do not get confused as you read materials in the Commission for Case Manager Certification’s (CCMC) CMBOK®, the expert contributors who developed the case management knowledge framework in 2009 decided to use the Commission’s definition of case management available at that time to guide their work. (Note that the definition below has since been updated to reflect current appropriate information promulgated by CCMC.) “Case management is a professional and collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs. It uses communication and available resources to promote health, quality, and cost-effective outcomes in support of the ‘Triple Aim,’ of improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” (CCMC, 2015, p. 4 )Case Management Philosophy and Guiding PrinciplesCase management is a specialty practice within the health and human services profession. Everyone directly or indirectly involved in healthcare benefits when healthcare professionals and especially case managers appropriately manage, efficiently provide, and effectively execute a client’s care. The underlying guiding principles of case management services and practices of the CMBOK follow:
Principal TermsMany terms in the CMBOK have multiple meanings, and you may be unclear about which meaning to apply. You might also not interpret the terms in the way the knowledge developers – who are case management experts – thought of them. To get the most out of the knowledge these experts have shared in the CMBOK, take the time to review the following terms. Note that the literature may describe these terms somewhat differently; the descriptions shared herein clarify their use throughout the CMBOK. Principal Terms Used in the CMBOK
The Case Management ProcessThe Case Management Process consists of nine phases through which case managers provide care to their clients: Screening, Assessing, Stratifying Risk, Planning, Implementing (Care Coordination), Following-Up, Transitioning (Transitional Care), Communicating Post Transition, and Evaluating . The overall process is iterative, non-linear, and cyclical, its phases being revisited as necessary until the desired outcome is achieved. It also is affected by the care setting where the client and client’s support system are being cared for and the practice setting of the case manager. Centering on a client and the client’s support system, the Case Management Process is wholistic in its approach to the management of the client’s situation and that of the client’s support system. It is adaptive both to the case manager’s practice setting and to the healthcare setting in which the client receives services. The High-Level Case Management Process
Case managers navigate the phases of the process with careful consideration of the client’s cultural beliefs, interests, wishes, needs, and values. By following the steps, they help clients/support systems to:
At the same time, case managers apply:
And at every phase of the Case Management Process, case managers provide vital documentation. Client SourceBefore looking more closely at the phases of the Case Management Process, first consider what triggers the process. You begin with the identification of a client. Without a client found to be in need of case management services, you have no need to launch the Case Management Process. The client source – that is, how you, as case managers, come in contact with clients and/or their support systems – varies based on your practice setting. Examples of Client Sources
The Screening Phase The Case Management Process: Screening View larger image Click here to view map key for image The
Screening phase focuses on the review of key information related to an individual’s health situation in order to identify the need for health and human services (case management services). Your objective of the screening as the case manager is to determine if your client would benefit from such services.
The Assessing PhaseThe Case Management Process: Assessing
Click here to view map key for image The Assessing phase involves the collection of information about a client's situation similar to those reviewed during screening, however to greater depth. The information you collect about your client/support system may include:
You, the case manager, have three primary objectives while assessing your client/support system:
You seek to confirm or update your client’s risk category based on the information you have gathered. You also may apply two key strategies for your effective information gathering. Using standardized assessment tools and checklists, you:
The Stratifying Risk PhaseThe Case Management Process: Stratifying Risk View larger image Click here to view map key for image The Stratifying Risk phase involves the classification of your client into one of three risk categories – low, moderate, and high – in order to determine the appropriate level of intervention based on your client’s situation and interests. This classification allows you to implement targeted risk category-based interventions and treatments that enhance your client's care interventions and outcomes. When stratifying your client’s risk, you as the case manager complete a health risk assessment and biomedical screening based on specific risk factors for your client. Factors applied in a client’s risk stratification may include:
In some organizations, such as those that are payor-based, stratifying risks may take place prior to assessing the client. It also may be completed in an automated fashion using decision support systems and based on claims data. In such situations, you as the case manager review the automatically generated risk classifications and contact the client accordingly. You may also determine the need for contacting the client based on agreed-upon and nationally recognized algorithms, criteria and protocols. It is common today to have a risk classification system that consists of four categories instead of three. The fourth and additional level refers to a small percentage of clients (i.e., no more than 3%) whose condition is extremely complex and requires an intensive amount of resources and the involvement of multiple healthcare providers with varied specialties. This group of patients is usually described as the “very high” risk category. When you are managing this category of clients, you provide comprehensive case management services while interacting with such clients at a frequency that exceeds once per month – as high as perhaps weekly. The Planning PhaseThe Case Management Process: Planning Click here to view map key for image The Planning phase establishes specific objectives, care goals (short- and long-term), and actions (treatments and services) necessary to meet a client's needs as identified during the Screening and Assessing phases. You often consider the client’s risk classification or category in the design of the client’s plan of care.During the Planning phase, you as the case manager develop a case management plan of care for your client that considers inputs and approvals of the client/support system and the client’s healthcare providers. Your plan is action-oriented, time-specific, and multidisciplinary in nature. In this plan you address your client's self-care management needs and care across the continuum, especially the services needed after a current episode of care; for example, care post hospital discharge such as home care services. In addition, the case management plan of care you develop identifies outcomes that are measurable and achievable within a manageable time frame and that apply evidenced-based standards and care guidelines. You finalize the Planning phase (i.e., development of a final case management plan of care for your client/support system) after you have received authorization for the health and human services from your client’s payor source and after the services and resources needed have been identified. The Implementing (Care Coordination) PhaseThe Case Management Process: Implementing (Care Coordination) View larger image Click here to view map key for image The Implementing phase centers on the execution of the specific case management activities and interventions that are necessary for accomplishing the goals set forth in your client’s case management plan of care. This is commonly known as care coordination. During this phase, you as the case manager organize, secure, integrate, and modify (as needed) the health and human services and resources necessary to meet your client's needs and interests. You also share key information on an ongoing basis with your client and client's support system, the healthcare providers/clinicians you are collaborating with, your client’s health insurance company/payor, and the representatives of community-based agencies you have engaged or will be engaging in the client’s care and case management plan. The Following-Up PhaseThe Case Management Process: Following-Up View larger image Click here to view map key for image The Following-Up phase focuses on the review, evaluation, monitoring, and reassessment of a client’s health condition, needs, ability for self-care, knowledge of condition and treatment regimen, and outcomes of the implemented treatments and interventions. Here your primary objective is to evaluate the appropriateness and
effectiveness of your client’s case management plan and its effect on your client’s health condition and care outcomes.
The Transitioning (Transitional Care) PhaseThe Case Management Process: Transitioning (Transitional Care) View larger image Click here to view map key for image The Transitioning phase focuses on moving a client across the health and human services continuum or levels of care depending on the client’s health condition and the needed services/resources. During this phase, you as the case manager prepare your client and client’s support system either for discharge from the current care setting/facility to home or for transfer to another healthcare facility or a community-based clinician for further care. These activities are commonly known today as transitional care or transitions of care. In order to maintain continuity of care, you apply this phase’s activities to completely execute your client’s transition to the next level of care. You ensure your client’s safe transition through careful communication with key individuals (including sharing of necessary information) at the next level of care or setting, your client and client's support system, and other members of the healthcare team. Additionally, you may:
The Communicating Post Transition PhaseThe Case Management Process: Communicating Post Transition View larger image Click here to view map key for image The Communicating Post Transition phase involves communicating with a client/support system for the purpose of checking on how things are going post transition from an episode of care. During this phase, you:
The Evaluating PhaseThe Case Management Process: Evaluating View larger image Click here to view map key for image The Evaluating phase calls for measuring the results of implementing the client’s case management plan of care (e.g., the objectives, goals, treatments and interventions, and return on investment) and their effect on a client's condition. In this evaluation, you focus on several types of outcomes of care:
During this phase, you as the case manager generate outcomes reports such as case summary, quality, cost/billing, satisfaction, outcomes, cost-benefit analysis, and return on investment. You also communicate the findings or disseminate the reports to key stakeholders such as government agencies (e.g., Centers for Medicare & Medicaid Services), the leadership team, client, payor, providers of care, employers, interdisciplinary team members, risk management staff, quality improvement team members, and others as deemed appropriate. Essential Domains of Case Management KnowledgeAlthough case managers practice in a variety of care settings and are from varied backgrounds, the Commission has now defined six essential knowledge domains that encompass the realm of case management work and that apply to all care settings, health disciplines, and professional backgrounds. Each domain is further organized into subdomains.
Care Delivery and Reimbursement MethodsThe Care Delivery and Reimbursement Methods domain consists of knowledge associated with the Case Management Process, systems of care provision, resources, and skills needed to ensure the effective and efficient delivery of safe, quality health and human services to clients/support systems. This domain also includes knowledge of reimbursement methods, funding sources, allocation of services and resources, and payor systems and concepts such as utilization review and management procedures. Applying such knowledge in the execution of your role and responsibilities as case manager enhances your performance and improves your productivity, which then ultimately results in enhanced care outcomes for both your client and employer (healthcare organization) alike. Success in your case manager’s role requires the work of a team: the client, the client’s support system, and the healthcare and
service providers, including payor representatives and other clinicians. © CCMC 2018. All rights reserved. View larger image The Care Delivery and Reimbursement Methods domain also focuses on knowledge associated with case management administration and leadership, with program design and structure, with roles and responsibilities of case managers in various settings, and with skills of case managers (e.g., communication, problem solving, conflict resolution, resilience, and others). Additionally, knowledge in this domain is associated with various healthcare delivery systems and models across the continuum of health and human services and case managers’ practice settings. It includes knowledge of case management models, concepts, processes, services, and resources. Moreover, this domain addresses other topics such as levels of care, transitions of care, and collaboration among the various people involved in care such as the clients themselves, their support systems, multi-specialty care providers, community agencies, and payors. Psychosocial Concepts and Support SystemsThe Psychosocial Concepts and Support Systems
domain consists of knowledge associated with the role clients’ cultures, values, beliefs, social networks, and support systems play in clients’ health and well-being, including health behavior and lifestyle. This domain also focuses on the impact of socioeconomic classes on clients’ health conditions, ability for self-care management, health engagement, health literacy and numeracy, and adherence to treatment regimen. Rehabilitation Concepts and StrategiesThe Rehabilitation Concepts and Strategies domain consists of knowledge associated with clients’ physical and occupational health and functioning, including catastrophic case management, workers’ compensation, vocational and disability concepts, strategies, and resources. This domain also includes knowledge of life care planning, roles and skills of various healthcare providers in rehabilitation care settings, return-to-work concepts and strategies, types of rehabilitation settings/facilities, and use of assistive devices or durable medical equipment for rehabilitation and vocational purposes. In addition, this domain includes regulations pertaining to rehabilitation. Quality and Outcomes Evaluation and MeasurementThe Quality and Outcomes Evaluation and Measurement domain consists of knowledge associated with quality management, accreditation standards, care quality and safety, demonstrating return on investment, and cost-effectiveness. In addition, this domain includes demonstrating the value of case management, case load calculation, tools such as case management plans of care, and regulations related to case management. Ethical, Legal, and Practice StandardsThe Ethical, Legal, and Practice Standards domain consists of knowledge about the case manager’s role as client advocate, and legal and ethical issues relevant to case management practice. This domain also focuses on:
Professional Development and AdvancementThe Professional Development and Advancement domain consists of knowledge associated with the roles and responsibilities of case managers in articulating, advancing, and demonstrating the value of case management practice. It also includes topics such as case managers’ involvement in scholarship activities (e.g., writing for publication, public speaking, research and utilization of evidence, training and education, and curriculum development), health or public policy work, accountability for ongoing education or learning, maintaining necessary skills and competencies for effective performance, engagement in practice innovation, and mentoring other case managers. Is intended to make the client and client concerns and strengths the focus of care?Focus Charting of F-DAR is intended to make the client and client concerns and strengths the focus of care. It is a method of organizing health information in an individual's record.
What is the purpose of the written client's record?The client health record is a legal document that records events and decisions which help the practitioner manage client care. It may also provide significant evidence in lawsuits, hearings or inquests when the client care provided by the practitioners is in question.
Is a formal legal document that provides evidence of a client's care?(Nurses always report on clients at the end of a work shift) Record - also called a chart or client record, is a formal, legal document that provides evidence of a client's care (written or computer based).
Which nursing qualities are helpful in winning the confidence?Nursing standards of conduct require confidence in their nursing skills and practice. Self-awareness and a desire for personal and professional improvement on the nurse's side can help build, maintain, and boost confidence.
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