By Toni Cesta, PhD, RN, FAAN

Introduction

RN case managers and social workers are key advocates in the delivery of quality healthcare. Their broad skills and training allow them to assess patients’ needs and work well with families and other members of the healthcare team. Negotiating, collaborating, communicating, team-building, precepting, educating, and consulting are the basis of what a successful case manager brings to the care setting each day. This month will begin a discussion of the skill sets every case manager and social worker should possess to be as effective in the role as possible. These skills form the foundation of an effective case manager.

Case management is a collaborative process used to assess, plan, implement, coordinate, monitor, and evaluate options and services to meet individuals’ health needs through communication and available resources to promote quality, cost-effective outcomes.

The RN case manager and social worker’s expertise is the vital link between the individual, the provider, the payer, and the community. Successful outcomes cannot be achieved without using the specialized skills and knowledge applied through the case management process. Not everyone possesses the skills necessary to become a successful case manager. Case managers and social workers must be clinically astute and competent in their areas of practice. It is important for case managers to be skilled in using the case management process and to acquire the assessment skills to identify the patient’s actual and potential health problems. This allows them to implement the required interventions to successfully resolve these problems, and to evaluate the outcomes of care and responses to treatments.

Assessment is an ongoing and continuous process occurring with all patient-case manager/social worker interactions. During the assessment phase, the case manager seeks a better understanding of the patient, family dynamics, and healthcare beliefs and/or myths. An assessment involves three phases, which at times seem inseparable: gathering data, evaluating data, and determining an appropriate plan. Case managers use a multifaceted subgroup of skills to accurately assess a patient’s needs:

Skills for Effective Case Management

• Assessment;

• Planning;

• Implementation;

• Coordination;

• Evaluation.

Leadership Skills

• Patient advocate;

• Facilitator;

• Negotiator;

• Quality improvement coordinator;

• Resource manager;

• Educator;

• Financial analyst;

• Decision-maker;

• Critical thinker;

• Data manager and analyst.

Communication/Interpersonal Skills

• Team-building;

• Customer relations;

• Public speaking;

• Conflict resolution;

• Delegation;

• Information sharing;

• Systems thinking;

• Emotional intelligence.

As an assessor, the case manager must obtain relevant data through skillful investigation. All information related to the plan must be evaluated with a critical eye to objectively identify trends, set and reset realistic goals, and seek viable alternatives when necessary. A vital case management skill is the ability to recognize a patient’s health problems and formulate action plans based on data collected during the assessment. The diagnoses express the case manager’s judgment of the patient’s clinical condition, functional abilities, responses to treatments, healthcare needs, psychosocial supports, financial status, and post-discharge needs.

Planning

Planning is the next step in managing the patient’s care. This is accomplished by planning the treatment modalities and interventions necessary for meeting the needs of the patient and family. During the planning phase, the case manager, in collaboration with other members of the healthcare team, determines the goals of treatment and the projected length of stay. Immediately after admission, the case manager initiates the transitional plan of care. The determination of goals is vitally important because it provides a clear time frame for accomplishing the care activities. Case managers must identify immediate, short-, and long-term needs, as well as where and how to meet these needs.

Planning is initiated on admission or before admission, when possible. The case manager’s clinical expertise is needed when establishing whether the treatment plan and interventions are appropriate. Data are gathered, plans are established, and an interdisciplinary care plan begins to unfold.

Throughout the acute hospital, subacute, home care, or long-term care stay, the case manager monitors and re-evaluates the plan for accuracy as the patient’s condition changes. As a planner, the case manager identifies a treatment plan while remaining cognizant of outcomes and minimization of unnecessary costs. The case manager must include the patient and family in decision-making and consider the patient’s goals as an integral part of the care plan. Alternate plans must always be incorporated in anticipation of sudden shifts in the treatment process or in response to treatments yielding complications.

Implementation and Coordination

Implementation and coordination involve building the plan, determining the goals of care, and deciding how to make a viable and realistic plan move to completion. The case manager’s goal is to give the patient and family the knowledge, attitudes, and skills necessary to implement the plan. Through communication, collaboration, and teaching, the case manager works with the interdisciplinary team to motivate the patient to succeed in meeting the goals of care.

As the patient nears discharge, the case manager can take three steps to improve the chances of effective implementation: clarifying the transfer of responsibilities of care, reviewing the plan to ensure nothing has been overlooked, and making last-minute alterations and arrangements for the immediate discharge period.

Evaluation

The final step in the case management process is designed to measure the patient’s response to a formulated plan, and ensure the appropriateness of the care plan and the quality of the services and products offered.

To achieve successful evaluation and outcomes, the case manager must routinely assess and reassess the patient’s status and progress toward reaching the goals of the care plan. If the situation is at a halt or regressing, the case manager must make appropriate adjustments and alter the plan accordingly.

As the evaluation proceeds, ask these important questions:

• Were the patient’s needs identified early in the hospital stay?

• Were learning goals identified and teaching documented?

• Were referrals complete and timely?

The Importance of Confirming the Plan

Taking the time to confirm the care plan greatly increases the chances of effective and efficient implementation. Follow-through will help ensure the goals are met.

• Could the patient/family clearly verbalize the care goals?

• Were the patient’s/family’s problems resolved?

• Did the patient/family seem satisfied with the plan and the decisions surrounding the plan?

• Did the patient/family comply with medical advice and follow the recommendations of the case manager?

• Were the services provided appropriately and authorized by the managed care organization?

These questions will help the case manager determine if the discharge plan was effective, and will assist with quality improvement efforts for future patients.

Leadership Skills and Functions

The case manager must use many leadership skills and functions to effectively master the case management process. Because case managers serve as problem-solvers, resource managers, and members of the interdisciplinary healthcare team, they should be well-trained in various leadership qualities. Nurse case managers and social workers must be adept at negotiating, making sound decisions, and resolving conflicts. To do this successfully, nurses must use critical thinking and problem-solving skills.

Advocacy and Facilitation of Care

One of the most critical elements of the case manager and social worker role is as an advocate for the patient. The patient-case manager relationship is built on trust, to foster mutual respect between nurse and patient, and to establish a rapport that facilitates communication between the family, caregivers, payers, and other healthcare team members. As case managers gain a clearer understanding of the patient’s needs and goals, they communicate this understanding to the members of the healthcare team. They also monitor the course of treatment to affect an earlier discharge or arrange for more efficient home care services. As a facilitator, the case manager can be a catalyst for change by empowering the patient or family members to seek solutions throughout the acute care phase and beyond. The case manager always looks for quality improvement that could result in potential cost savings, or possibly prolong healthcare benefits.

Advocacy Skills

Case managers and social workers can best advocate for patients and their families if they:

• Keep the patient’s best interest paramount in the process of care delivery;

• Recommend, coordinate, and facilitate the most effective plan of care;

• Protecting the rights of patients;

• Communicate to other providers and document the patient’s care preferences;

• Facilitate the patient and family’s decision-making activities by keeping them well informed of their rights and options;

• Clarify the goals of therapy and treatment;

• Determine the appropriateness of the post-discharge services and the discharge/transitional plan;

• Ensure the interventions are consistent with the patient’s needs and goals of treatment;

• Maintain the patient’s privacy and confidentiality;

• Negotiate on behalf of the patient/family with the managed care organization for authorizations of services;

• Facilitate resolution of ethical conflicts;

• Stay abreast of the legal and ethical requirements and standards of patient care delivery;

• Prevent delays and variances in care delivery.

Clinical Reasoning and Critical Thinking

Problems involving the patient, family, and healthcare provider are inevitable. It is important for case managers to solve these problems. The ability of case managers to provide safe, efficient, and competent services depends heavily on their skills in problem-solving, clinical reasoning, and critical thinking. These skills have one thing in common: They all entail the generation of possible solutions to problems, issues, or concerns regarding patient care delivery and options. Case managers use their clinical knowledge, expertise, and leadership skills for this purpose. They capitalize on their role as informal leaders of the healthcare team and facilitators of care delivery to solve these problems.

Case managers are constantly making decisions. They decide what observations should be made, derive meaning from these observations, and decide the course of action. The overall goal is the delivery of optimal, cost-effective, quality care.

Case managers use a framework for decision-making and problem-solving that bridges the present and the future. They assess the patient and family’s current state, and anticipate the future goals and expected outcomes of the treatments. They create an action plan to bring the patient and family to the desired future state. This framework enhances an outcomes-based approach to the delivery of case management services. Usually, the plan is interdisciplinary and implemented only after approval by the healthcare team and consent from the patient and family. Understanding that the action plan may not always result in a resolution of the patient’s issues, case managers engage in constant reassessment, monitoring, evaluation, and revising of the plan until the desired outcomes are achieved.

The case manager’s decision-making, clinical-reasoning, and judgment skills must always help the patient work through the confusion he or she faces in the complex healthcare environment. Case managers operate by answering questions pertinent to developing the care plan, actual delivery of care, and evaluation of the discharge plan:

• Is the treatment plan appropriate enough to resolve the patient’s problems?

• Will the case management action plan prevent readmission?

• Are the treatments provided the best possible treatments for the patient and family?

• Do healthcare team members agree with the plan?

• Do the patient and family have any issues or disagreements with the plan?

• Should any changes be made to the plan of care or discharge plan?

• Will the electricity in the home support a mechanical ventilator?

• Does the patient have safe access to a bathroom on the main floor of the house?

• Is it worth the hospital’s financial support to fly a patient out of state rather than incur the cost of an extended stay?

• Can the family learn how to perform tracheal suctioning so that their loved one can go home with them rather than to an extended nursing facility?

Answers to these questions influence the type of care a patient will receive and how it will be accomplished to ensure the best possible outcome in the most cost-effective manner. Case managers who can apply critical thinking and clinical reasoning skills in the decision-making process ensure appropriate, effective, and efficient care delivery. This means that the patient and family will receive the necessary support, potential obstacles will be avoided, the potential for readmission will decrease, the educational component of care will be reinforced, and a positive outcome will occur.

Negotiation

Negotiation is a skill that is not primarily taught in nursing or social work education programs. To be a successful negotiator, a case manager must be a good time manager. Along with managing their own time, case managers must learn to determine what work others can and should perform in assessing a patient’s needs when preparing a care plan. This understanding allows them to negotiate more effectively.

Negotiation in case management is an everyday occurrence. It is a skill used with payers and providers, with vendors for durable medical equipment, with the patient and family/caregiver, and even with physicians reluctant to opt for a home care discharge plan or placement in a long-term care facility.

Fair negotiation requires trust, rapport, and complete honesty regarding a patient’s care needs. Successful negotiation is achieved by presenting the facts clearly and succinctly. To know if you have negotiated your case well, you must be a good listener who tunes in to verbal and nonverbal cues; otherwise, windows of opportunity can be missed. On the financial side, nurses know all too well that healthcare environments are committed to doing more with less, and at a lower cost. Financial prowess is a must in these times of cost containment. Case managers must work with financial support personnel and help them keep abreast of a patient’s insurance benefits.

Summary

This month, we began our discussion on the skills needed to be an effective RN case manager or social worker in today’s complex healthcare systems. The necessary skills far exceed those acquired through one’s professional licensure, and require expanded knowledge and skill sets to be a proficient case management professional. Next time, we will continue the review of the leadership and communication skills needed to be a successful case manager.