What consumer should expect from case management

Communication is important part of the process

By Sherry L. Aliotta, RN, BSN, CCM

President/CEO
S.A. Squared, Inc.
Farmington Hills, MI

When a consumer is assigned a case manager, he or she should have expectations that case managers should be prepared to meet.

Consumers should expect to consent to case management services, to know that a case manager is involved, who the case manager is affiliated with, who will know what they tell the case manager, and how information will be disclosed. They should also be educated on the process we that we will follow to help them.

Clients should expect to talk to their case manager. No one can be their advocate, planner, facilitator, assessor, problem solving consultant, guide, or connector without having talked to the client.

The communication may begin with the initial assessment, but it should not end there. Case managers should be in regular contact with the consumer to make sure they are informed and participating.

Advocacy is incomplete unless the individual is educated to be as self-reliant as possible. Even in cases where the case manager must act as the individual’s advocate, the patient should be as aware and involved as their circumstances allow. The consumer should learn about the system, about their illness, about what they can do to manage it, about when to seek help, from whom to seek help, and hundreds of other issues that are as diverse as the people we serve.

Consumers should expect to participate in their care and goal-setting. Levels of participation may vary with individuals, but they should expect to have their interests represented and honored every step of the way. Through the learning process individuals should be empowered to be the primary decision makers. Goals should be theirs, not ours.

In order to participate fully, consumers need to understand the case management process. How do we identify them and how do they identify us? How do we decide which individuals need case management and which ones do not? How do they reach us? How can they access case management information? How do we decide when our involvement ends?

No one can fully participate in a process until they understand it. Not everyone will want all of this information, but the case manager should make sure that there is sufficient understanding to allow for full participation at the level desired.

They should expect competence. The case manager should be fully qualified to advise consumers with the health problems and issues common to the consumer group they serve. This includes cultural competency. Case managers must maintain their proficiency through continual learning.

They should expect integrity and ethical practice. Ethical practice includes respect for the individual’s autonomy and adherence to ethical principles. Codes of conduct and ethical standards for case management are published and available. Sadly, many case managers are not aware of their existence. This is not to say that these case managers are practicing in an unethical manner. It is merely evidence of yet another gap in creating consistency and awareness within case management. Again, if we are not clear within the practice, how can we clarify the issue for consumers?

They should expect that the case manager could work with them across the continuum of care, or at least have a clear understanding of the scope of case managers. The ideal circumstance involves a case manager who can work with the client regardless of care setting, payer source, or other system inspired boundaries.

In the absence of the ideal, the consumer should expect to know how long and under what circumstances the case manager will be involved and who will be available when one case manager must cease involvement.

These expectations exist as my opinion only, although it is inspired by existing works such as the CMSA Standards of Practice for Case Managers and the URAC Standards for Case Management Organizations. While this list not meant to be prescriptive or all-inclusive, it is representative of the type of communications we must have with case management consumers. It is a part of clarifying our identity and creating accountability to those we are here to serve.

Steps in the case management process

Assessment/Case Identification and Selection – we have to take a thorough and objective look at the entire situation and use that data to clearly help the individual identify the problem.

Problem Identification – it is not enough to simply name the problem, we have to help the individual understand its roots, its impact, and why it persists.

Planning – we have to work with our client and all those involved with the problem and its solution to develop a plan that reduce or eliminate the problem. This involves identifying the connections that must be made and the resources that must be involved.

Monitoring – we have to see how the plan is working and make sure everyone on the problem solving team has input into deciding how we are doing and if changes are needed.

Evaluating – we have to evaluate the very services that the health care system offers us as tools. Do we have the right resources? Are they effective? Is their quality matching our client’s expectations?

Outcomes – we have to work with problem solving team to determine how well we did at solving the problem. What was the impact? We have to help the team answer the question, "so what"?