Chapter 2

Essential Skills for Case Managers

2.1 Essential Skill Overview

If you ask ten people what case management means to them, you will most likely
get ten different answers. Though case management has been around since the late
70s, there has not been a clear understanding of the role. There may be several
reasons for the lack of clarity. The practice of case management extends across all
health care settings, including payer, provider, government, employer, community,
and home environment. The practice also varies in degrees of complexity and
comprehensiveness based on the setting, health conditions, reimbursement, and
healthcare profession (Powell and Tahan 2008).
Since the enactment of the Health Maintenance Organization Act of 1973, case
managers have been working to develop and define the role. The work of the Case
Management Society of America (CMSA) has been instrumental in the develop-
ment and standardization of the practice of case management. Founded in 1990,
CMSA (www.cmsa.org) is the leading non-profit association dedicated to the
support and development of case management. The CMSA developed Standards of
Practice that utilize the essential skills of case managers to provide a foundation
for all case managers, regardless of practice setting. The standards were first
published in 1995 and revised in 2002 and 2010. The majority of case management
programs today are based on the CMSA standards (http://www.cmsa.org/portals/0/
pdf/memberonly/StandardsOfPractice.pdf).
The case manager performs the primary functions of assessment, planning,
facilitation and advocacy, which are achieved through collaboration with the
patient and other health care professionals involved in the patient’s care. Key
responsibilities of case management have been identified by nationally recognized
professional societies and certifying bodies through case management roles and
functions research. When asked to describe the essential skills necessary for an
effective case manager, it was best to work from the CMSA standards of practice

 The Author(s) 2015 17

J. Treadwell et al., Case Management and Care Coordination,
SpringerBriefs in Child Health, DOI 10.1007/978-3-319-07224-1_2
18 2 Essential Skills for Case Managers

which really are the ‘‘gold standards’’ for case management. This chapter will
discuss how case managers use specific skills within their practice to achieve
standards of practice. Twelve standards will be used to example essential case
management skills.
The CMSA guiding principles for case management include:
• Using a patient-centric, collaborative partnership approach.
• Facilitating self-determination and self-care through the tenets of advocacy,
shared decision making and education.
• Using a comprehensive, holistic approach.
• Practicing cultural competence with awareness and respect for diversity.
• Promoting the use of evidence-based care.
• Promoting optimal patient safety.
• Promoting the integration of behavioral change science and principles.
• Linking with community resources.
• Assisting with navigating the health care system to achieve successful care, for
example during transitions.
• Pursuing professional excellence and maintain competence in practice.
• Promoting quality outcomes and measurement of those outcomes.
• Supporting and maintaining compliance with federal, state, local, organiza-
tional, and certification rules and regulations CMSA (2010) Standards of
Practice for Case Management.
As you look at the guiding principles it is easy to see that a professional case
manager who can facilitate these operations must have a basic set of skills in
addition to their foundational healthcare license. For example, using a patient-
centered approach is apart from the traditional model of health care. Case man-
agers have collaboration as an essential skill as they come from a place of no
formal authority to shale relationships and actions of children/families and their
care providers. Another important skill set is cultural competency and use of
reflective practice. Knowing that the family are the ultimate decision makers in
care decisions and practices translates to a required skill set impacting a case
manager’s approach to families and use of education, self-management tools, and
shared -decision making. An effective case manager realizes they are dealing with
individuals with different value systems, cultural beliefs, and socioeconomic
backgrounds. There are generally no negative consequences for non-adherence to a
plan of care other than recurrent signs and symptoms of the underlying disease.
The effectiveness of a case manager really stems from an individual who is truly
passionate about what they do and knows how to communicate with patients and
support systems in a way in which they can fully understand their diagnosis,
treatment expectations, desired outcomes, and consequences for non-adherence.
2.2 Standard #1: Patient Selection Process for Case Management 19

2.2 Standard #1: Patient Selection Process

for Case Management

The case manager should identify and select patients who can most benefit from
case management services available in a particular practice setting.
Not everyone needs or wants case management. Most programs use some form
of high-risk screening criteria to assess for inclusion in case management pro-
grams. The screening criteria generally include medical and psychosocial con-
siderations such as chronic, catastrophic, or terminal illness; social issues such as a
history of abuse, neglect, no known social support, or lives alone; repeated
admissions; and financial issues. The essential skill for the case manager is a
strong clinical background to understand the severity of a child’s clinical condition
combined with a proficient use of analytic tools that help identify risks and
priorities.
Tips for Parents: Try to identify barriers to care/adherence and whether a case manager
may be helpful in decreasing or eliminating the barriers to improve outcomes.

Tips for Healthcare Professionals: Case managers generally have the additional time to
spend with patients and support systems to perform a comprehensive assessment of a
situation and help identify barriers to care/adherence. In the situation where a case
manager has a complex patient or situation, a referral to a case manager for initial
screening may be beneficial.

2.3 Standard #2: Patient Assessment

The case manager should complete a health and psychosocial assessment, taking
into account the cultural and linguistic needs of each patient.
This is a very important step in the case management process and it may take
several conversations with the child/family, and providers to get a comprehensive
picture of the care needs and barriers. A good case manager is able to ask the right
questions to get to the heart of an issue. Sources of information can include patient/
support systems interviews, healthcare provider discussions, medical records,
claims data, and utilization history. The information included in the assessment
may vary depending on the reason for the case management referral but generally
include physical, psychosocial, and functional components. Caregiver support is
very important for patients unable to provide self-care. Case managers as educa-
tors can present information in an understandable was, noting the health literacy
level of families, to make sure families are able to participate as informed con-
sumers understanding their choices in care decisions.
20 2 Essential Skills for Case Managers

2.4 Standard #3: Problem Opportunity/Identification

The case manager should identify problems or opportunities that would benefit
from case management intervention.
The most important point to make is that the patient/support systems are in
agreement regarding the problems/opportunities identified. If the patient does not
consider a certain behavior a ‘‘problem’’ he/she will see no reason to change the
behavior. If the patient in engaging in harmful behavior but is not willing to
recognize the behavior as harmful or change it, the role of the healthcare provider
is to educate the patient regarding the potential negative consequences of that
behavior and hopefully revisit it in future interactions. The essential skill for
assessment is the communication technique of motivational interviewing which
supports families in considering their options and opportunities to achieve desired
goals.

2.5 Standard #4: Planning

The case manager should identify immediate, short-term, long-term, and ongoing
needs, as well as develop appropriate and necessary case management strategies
and goals to address those needs.
The patient/support systems must be involved in the plan of care and patient
preferences and desires have to be incorporated. There is not ‘‘one size fits all’’
plan of care. Customizing the plan to meets the needs of the patient is a key
component to adherence. Case managers incorporate the essential skill of orga-
nization, much as a project manager would move through any given assignment.
The case management process gives them a framework to follow to check mile-
stones and organize their process.
Tips for Parents: Make your preferences and needs known during the planning stage. The
goals must be reasonable and achievable and parental/caregiver input matters!

Tips for Healthcare Providers: Be sure the goals are objective and measureable. Use of
SMART goals is recommended:
Specific
Measureable
Attainable
Realistic
Timely

(Doran 1981).
2.6 Standard #5: Monitoring 21

2.6 Standard #5: Monitoring

The case manager should employ ongoing assessment and documentation to

measure the patient’s response to the plan of care.
Once the plan of care has been outlined, the case manager will monitor the
progress of the patient towards the desired outcomes. Having SMART goals makes
the process of monitoring easier. During this process, the case manager may also
serve as an educator and coach, facilitating movement toward desired outcomes.
Ultimately the patient/support systems are responsible for adherence to the plan of
care, but they may need the guidance and encouragement along the way. The case
manager will document ongoing collaboration with the patient, support systems or
caregiver, providers, and other pertinent stakeholders, so that the patient’s
response to interventions is reviewed and incorporated into the plan of care.
Changing behaviors can be difficult especially when habits have been formed.
As mentioned previously, case managers cannot make anyone do anything. People
generally will not make changes unless they realize a significant benefit and are
ready to try. One of tools used to determine a patient’s readiness to change is
motivational interviewing (http://pharmacy.auburn.edu/barkebn/Resume/Teaching
%20Motivational%20Interviewing%20with%20a%20Virtual%20Patient.htm)
(Auburn University Motivational Training Institute 2009).
Once again you see the skill of motivational interviewing (MI) as an important
approach to improving adherence first reported in the addiction literature (Rollnick
et al. 2008). It is a process used to determine readiness to engage in a target
behavior (e.g. taking a medicine as prescribed) in order to apply specific verbal
skills and strategies based upon the patient’s level of readiness. MI increases
treatment adherence by stimulating or enhancing the patient’s intrinsic motivation
in order to address and resolve ambivalence and resistance (major barriers to
adherence) rather than by providing extrinsic motivation in the form of arguments,
advice, and orders.
Monitoring will include verification that the plan of care continues to be
appropriate, realistic, understood, accepted by the child/family and supported by
the care team. The plan of care may need to be revised due to changes in the
patient’s condition, lack of response to the care plan, preference changes, transi-
tions across settings, and newly identified barriers to care and services. An
effective case manager realizes things may not always go as planned and will have
recommendations for alternative plans of care.
Tips for Parents: Ask yourself, ‘‘do I really think there is a problem with my child and am I
willing to commitment to making the necessary changes to improve adherence?’’
22 2 Essential Skills for Case Managers

2.7 Standard #6: Outcomes

The case manager should maximize the patient’s health, wellness, safety, adap-
tation, and self-care through quality case management, patient satisfaction, and
cost-efficiency.
Case mangers work with patients and support systems to provide support and
guidance which hopefully results in achieving the outcomes outlined in the plan of
care. Case management is an outcome driven process that is time limited. The
expectation is the child/family, as possible, will ultimately take full responsibility
for adhering to the plan of care independent from the case manager. The essential
skill of collaboration is put into place when maximizing recovery through con-
nection to community resources, facilitating integration at school and in other
areas of interest to the child such as sport opportunities. The concept of self-care
should be stressed from the very beginning and throughout the case management
process. If the patient is unable to engage in self-care, the case manager will work
to offer suggestions for caregivers and alternative support systems.

2.8 Standard #7: Termination of Case Management

Services

The case manager should appropriately terminate case management services

based upon established case closure guidelines.
These guidelines may differ in various case management practice settings. As
stated earlier, case management is time limited process with the expectation that
the patient will become independent in adhering to the plan of care.
However, sometimes there is the necessity to support families through a case
where the opportunities for self-management will not be possible. The essential
skill of life care planning incorporates a range of service the case manager can
support focusing on what will be the required needs of the individual throughout
their life course to support them in meeting their goals.
An effective case manager maintains open communication with patients and
healthcare providers regarding the potential termination of case management
services well before services are terminated. Patients and healthcare providers
should feel comfortable with the termination of services and confident that the
patient can do it independently.
2.9 Standard #8: Facilitation, Coordination, and Collaboration 23

2.9 Standard #8: Facilitation, Coordination,

and Collaboration

The case manager should facilitate coordination, communication, and collabo-

ration with the patient and other stakeholders in order to achieve goals and
maximize positive patient outcomes.
The healthcare system is complex and sometimes hard to navigate. Case
managers can be instrumental in developing proactive, patient-centered relation-
ships and communication with the patient, and other necessary stakeholders to
maximize outcomes. Patients may see several healthcare providers and obtain care
from a variety of facilities. Communication between providers may be minimal or
non-existent, with no single entity providing oversight for the plan of care. The
case manager may become instrumental in collaborating with the various entities
to ensure that all parties are aware of the plan of care that has taken into con-
sideration the personal preferences of the patient.
An essential skill for an effective case manager is the ability to negotiate; to
reconcile potentially differing points of view. Not everyone sees things the same
way which can sometimes the biggest barrier to developing the plan of care. The
role of the case manager includes clearly communicating the pros and cons of a
treatment plan. Laying all of the cards on the table so patients can make a fully
informed decision regarding what they want to do moving forward.

2.10 Standard #9: Qualifications for Case Managers

Case managers should maintain competence in their area(s) of practice by having

one of the following:
1. Current, active, and unrestricted licensure or certification in a health or human
services discipline that allows the professional to conduct an assessment
independently as permitted within the scope of practice of the discipline; and/
or
2. Baccalaureate or graduate degree in social work, nursing, or another health or
human services field that promotes the physical, psychosocial, and/or voca-
tional well-being of the persons being served. The degree must be from an
institution that is fully accredited by a nationally recognized educational
accreditation organization, and the individual must have completed a super-
vised field experience in case management, health, or behavioral health as part
of the degree requirements.
There are people in a variety of settings, with a variety of experiences and
education, holding the title of case manager. The interventions provided vary
greatly based on the patient population and practice setting. It is also important
maintain compliance with national and/or local laws and regulations that apply to
24 2 Essential Skills for Case Managers

the jurisdictions(s) and discipline(s) in which the case manager practices.

Healthcare is an ever changing field which requires case managers to maintain
competence through relevant and ongoing continuing education, study, and con-
sultation. Most importantly, a case manager must practice within their area(s) of
expertise, making timely and appropriate referrals to, and seeking consultation
with, others when needed.
Tips for Parents: When working with a case manager, inquire about their credentials,
educational background, and experience.

2.11 Standard #10: Legal

The case manager should adhere to applicable local, state, and federal laws, as
well as employer policies, governing all aspects of case management practice,
including patient privacy and confidentiality rights. It is the responsibility of the
case manager to work within the scope of his/her licensure.
This standard is broken down into two main areas, Confidentiality/Patient
Privacy and Consent for Case management.

2.11.1 Confidentiality and Patient Privacy

The case manager should adhere to applicable local, state, and federal laws, as
well as employer policies, governing the patient, patient privacy, and confidenti-
ality rights and act in a manner consistent with the patient’s best interest.
Privacy laws do change and it is the responsibility of the case manager to
maintain up-to-date knowledge of, and adherence to, applicable laws and regu-
lations concerning confidentiality, privacy, and protection of client medical
information issues.
Maintaining confidentiality of protected health information (PHI) is an
important part of the case manager’s practice. Case managers work closely with
patients and support systems and often collect information that is highly sensitive.
Case managers must remember they cannot share patient specific information with
other individuals without the consent of the patient.

2.11.2 Consent for Case Management Services

The case manager should obtain appropriate and informed patient consent before
case management services are implemented.
2.11 Standard #10: Legal 25

Patients need to be actively involved in the plan of care for adherence to occur.
Getting the patient’s consent to engage in the case management process is the first
step towards obtaining some level of commitment by the patient. Patients need to
understand the role and objectives of a case manager which should be shared prior
to obtaining patient consent. Sharing this information allows the patient to make an
informed consent. There should be some evidence that the patient and support
systems where thoroughly informed of the following:
• Proposed case management process and services relating to the patient’s health
conditions and needs
• Possible benefits and costs of such services
• Alternatives to the proposed services
• Potential risks and consequences of the proposed services and alternatives
• Client’s right to refuse the proposed case management services, and potential
risks and consequences related to such refusal
An effective case manager validates throughout the process that the patient is
the ‘‘driver’’ of the plan of care with the expectation that the case manager will
decrease their involvement as the patient works toward self-efficacy.

2.12 Standard #12: Advocacy

The case manager should advocate for the patient at the service-delivery, benefits-
administration, and policy-making levels.
Navigating the healthcare system can be confusing and complex. Case man-
agers are instrumental in facilitating access to necessary and appropriate services
while educating the patient and support systems about resource availability within
practice settings and the community. Case managers promote patient self-deter-
mination, informed and shared decision-making, autonomy, and self-advocacy.
Case managers identify the needs, strengths, and goals of the patient and incor-
porate this information into the plan of care. Case managers recognize and try to
eliminate disparities in accessing high quality care. Such disparities may be related
to race, ethnicity, national origin, sex, sexual orientation, age, religion, political
beliefs, physical, mental, or cognitive disability.

2.13 Standard #13: Cultural Competency

The case manager should be aware of, and responsive to, cultural and demo-
graphic diversity of the population and specific patient profiles.
People come from different countries, hold different beliefs, and embraced a
variety of cultural norms. Cultural differences need to be incorporated into the plan
of care to enhance adherence. An effective case manager understands relevant
26 2 Essential Skills for Case Managers

cultural information and communicates effectively, respectfully, and sensitively

within the patient’s cultural context. Language barriers may also be instrumental in
adherence. Assessment of patient’s linguistic needs and identifying resources to
enhance proper communication is very important. Patients cannot adhere to a plan
of care if they are unable to understand what is expected of them. Case managers
may need to use an interpreter and written materials in the appropriate language.
An understanding of cultural communication patterns of speech volume, context,
tone, kinetics, space, and other similar verbal/nonverbal communication patterns
can be helpful.

References

Auburn University Motivational Training Institute. 4–6 Dec 2009.

Case Management Society of America. Case management adherence guidelines. Retrieved from
http://www.cmsa.org/CMAG.
CMSA. (2010). Standards of practice for case management. Retrieved from http://www.cmsa.
org/Individual/MemberToolkit/StandardsofPractice/tabid/69/Default.aspx.
Doran, G. T. (1981). There’s a S.M.A.R.T. way to write management’s goals and objectives.
Management Review, 70(11), 35–36. Retrieved from http://www.ncdhhs.gov/
humanresources/pms/pm/smart.pdf.
Powell, S. K., & Tahan, H. A. (2008). CMSA core curriculum for case management (2nd ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Rollnick, S., Miller, W., & Butler, C. (2008). Motivational interviewing in health care. New
York, NY: Guilford Press.
http://www.springer.com/978-3-319-07223-4