Case Management Knowledge

The case management knowledge framework consists of what case managers need to know to effectively care for clients and their support systems. It includes a nine-phase Case Management Process and seven essential knowledge domains applicable in any care or practice setting and for the various healthcare professionals who assume the case manager’s role.

Definition of Case Management

There is no one standardized or nationally recognized and 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. 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 twenty or so definitions of case management considered appropriate. These definitions are available in peer-reviewed professional case management literature or on Web sites of case management (or case management-related) organizations, societies, and agencies.

The Case Management Knowledge Framework

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So that you do not get confused as you read material in the Commission for Case Manager Certification’s CMBOK®, the expert contributors who developed the case management knowledge framework decided to use the Commission’s definition of case management to guide their work:

“Case management is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client’s health and human services needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes.” (CCMC, 2010, p. 3)

 

Case Management Philosophy and Guiding Principles

Case 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:

  • Case management is not a profession unto itself. Rather, it is a cross-disciplinary and interdependent specialty practice.
  • Case management is a means for improving clients’ health and promoting wellness and autonomy through advocacy, communication, education, identification of service resources, and facilitation of service. Case management is guided by the principles of autonomy, beneficence, nonmaleficence, and justice.
  • Case managers come from different backgrounds within health and human services professions including nursing, medicine, social work, rehabilitation counseling, workers’ compensation, and mental and behavioral health.
  • The primary function of case managers is to advocate for clients/support systems. Case managers understand the importance of achieving quality outcomes for their clients and commit to the appropriate use of resources and empowerment of clients in a manner that is supportive and objective.
  • Case managers’ first duty is to their clients – coordinating care that is safe, timely, effective, efficient, equitable, and client-centered.
  • Case management services are offered according to the clients’ benefits as stipulated in their health insurance plans.
  • The Case Management Process is centered on clients/support systems. It is holistic in its handling of clients’ situations (e.g., addressing medical, physical, emotional, financial, psychosocial, behavioral, and other needs), as well as that of their support systems.
  • The Case Management Process is adaptive to case managers’ practice settings and the settings where clients receive health and human services.
  • Case managers approach the provision of case-managed health and human services in a collaborative manner. Professionals from within or across healthcare organizations (e.g., provider, employer, payor, and community agencies) and settings work together closely for the benefit of clients/support systems.
  • The goals of case management are first and foremost focused on improving clients’ clinical, functional, emotional, and psychosocial status.
  • The healthcare organizations for which case managers work may also benefit from case management services. They may realize lowered health claim costs (if payor-based), shorter lengths of stay (if acute care-based), or early return to work and reduced absenteeism (if employer-based).
  • All stakeholders benefit when clients reach their optimum level of wellness, self-care management, and functional capability. These stakeholders include the clients themselves, their support systems, the healthcare delivery systems including the providers of care, the employers, and the various payor sources.
  • Case management helps clients achieve wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, service facilitation, and use of evidence-based guidelines or standards.
  • Based on the cultural beliefs, values, and needs of clients/support systems, and in collaboration with all service providers (both healthcare professionals and paraprofessionals), case managers link clients/support systems with appropriate providers of care and resources throughout the continuum of health and human services and across various care settings. They do so while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. This approach achieves optimum value and desirable outcomes for all stakeholders.
  • Case management services are optimized when offered in a climate that allows direct, open, and honest communication and collaboration among the case manager, the client/support system, the payor, the primary care provider (PCP), and all other service delivery professionals and paraprofessionals.
  • Case managers enhance the case management services and their associated outcomes by maintaining clients’ privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards and guidelines, as appropriate to the practice setting.
  • Case managers must possess the education, skills, knowledge, competencies, and experiences needed to effectively render appropriate, safe, and quality services to clients/support systems.

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Principal Terms

Many 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.


Principal Terms Used in the CMBOK

Term Description
Client The recipient of case management as well as health and human services. “This individual can be a patient, beneficiary, injured worker, claimant, enrollee, member, college student, resident, or health care consumer of any age group” (CMSA, 2010, p. 24).
NOTE: In the CMBOK, the term client is sometimes intended to include the client’s support system.
Client's Support System The person or persons identified by each individual client to be directly or indirectly involved in the client’s care. It “may include biological relatives [family members], spouses, partners, friends, neighbors, colleagues, or any individual who supports the client [caregivers, volunteers, and clergy or spiritual advisors]” (CMSA, 2010, p. 24).
Caregiver The person responsible for caring for a client in the home setting and can be a family member, friend, volunteer, or an assigned healthcare professional.
Case Manager The health and human services professional responsible for coordinating the overall care delivered to an individual client or a group of clients, based on the client’s health or human services issues, needs, and interests.
Case Management Program Also referred to as case management department.
An organized approach to the provision of case management services to clients and their support systems. The program is usually described in terms of:
  • Vision, mission, goals and strategic objectives
  • Number and type of staff including roles, responsibilities, and expectations
  • A specific model or conceptual framework that delineates the key case management functions within the department
  • Reporting structure within the organization
Case Management Process The process through which case managers provide health and human services to clients/support systems. The process consists of several phases that are iterative, cyclical, and recursive rather than linear and that are applied until clients’ needs and interests are met. The phases of the process are Screening, Assessing, Stratifying Risk, Planning, Implementing (Care Coordination), Following-Up,Transitioning (Transitional Care), Communicating Post Transition, and Evaluating.
Case Management Plan of Care A comprehensive plan of care for an individual client that describes:
  • The client’s problems, needs, and desires, as determined from the findings of the client’s assessment.
  • The strategies, such as treatments and interventions, to be instituted to address the client’s problems and needs.
  • The measurable goals – including specific outcomes – to be achieved to demonstrate resolution of the client’s problems and needs, the time frame(s) for achieving them, the resources available and to be used to realize the outcomes, and the desires/motivation of the client that may have an impact on the plan (CMSA, 2010, p. 24).
Payor The person, agency, or organization that assumes responsibility for funding the health and human services and resources consumed by a client. The payor may be the client him/herself, a member of the client’s support system, an employer, a government benefit program (e.g., Medicare, Medicaid, TriCare), a commercial insurance agency, or a charitable organization.
Practice Setting (Also referred to as practice site, care setting, or work setting.) The organization or agency at which case managers are employed and execute their roles and responsibilities. The practice of case management extends across all settings of the health and human services continuum. These may include but are not limited to payor, provider, government, employer, community, independent/private, workers’ compensation, or a client’s home environment.
Professional Discipline Case managers’ formal education, training, and specialization or professional background that is necessary and prerequisite for consideration as health and human services practitioners. Also refers to the professional background – such as nursing, medicine, social work, or rehabilitation – that case managers bring with them into the practice of case management.
Knowledge Domain A collection of information topics associated with health and human services and related subjects. These topics are organized around common themes (domains) to form high-level/abstract concepts that are considered to be essential for effective and competent performance of case managers. Examples of case management knowledge domains are Principles of Practice and Healthcare Reimbursement.
Health An individual's physical, functional, mental, behavioral, emotional, psychosocial, and cognitive condition. It refers to the presence or absence of illness, disability, injury, or limitation that requires special management and resolution, including the use of health and human services-type intervention or resource.
NOTE: Throughout the CMBOK, the term health implies all aspects of health as described in the principal term, reflecting a holistic view of the client’s condition.
Health and Human Services Continuum The range of care that matches the ongoing needs of clients as they are served over time by the Case Management Process and case managers. It includes the appropriate levels and types of care – health, medical, financial, legal, psychosocial, and behavioral – across one or more care settings. The levels of care vary in complexity and intensity of healthcare services and resources, including individual providers, organizations, and agencies.
NOTE: Throughout the CMBOK, the term healthcare refers to and incorporates “health and human services,” reflecting the broader community of professionals who serve clients and the continuum of services they provide.
Level of Care The intensity and effort of health and human services and care activities required to diagnose, treat, preserve, or maintain clients’ health. Level of care may vary from least to most complex, least to most intense, or prevention and wellness to acute care and services.
Community Services and Resources Healthcare programs that offer specific services and resources in a community-based environment as opposed to an institutional setting (i.e., outside the confines of healthcare facilities such as hospitals and nursing homes). These programs either are publicly or privately funded or are charitable in nature.
Benefit Programs The sum of services offered by a health insurance plan, government agency, or employer to individuals based on some sort of an agreement between the parties (e.g., employer and employee). Benefits vary based on the plan and may include physician and hospital services, prescriptions, dental and vision care, workers’ compensation, long-term care, mental and behavioral health, disability and accidental death, counseling, and other therapies such as chiropractic care.
Benefits The type of health and human services covered by a health insurance plan (sometimes referred to as health insurance benefits, health benefits, or benefits plan) and as agreed upon between an insurance company and an individual enrollee or participant. The term also refers to the amount payable by an insurance company to a claimant or beneficiary under the claimant's specific coverage as stipulated in the health insurance plan.
Services Interventions, medical treatments, diagnostics, and other activities implemented to manage clients’ conditions, including health and human services issues and needs. The types of services implemented can be found in an individual client’s case management plan of care, medical treatment plan, or other related documents as applicable to the healthcare setting and the professional discipline of the provider of care and services.
NOTE: The term services is used generically in the CMBOK to include the various types of care and services described above.
 

The Case Management Process

The 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 and cyclical, its phases being revisited as necessary until the desired outcome is achieved.

Centering on a client and the client’s support system, the Case Management Process is holistic 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:

  • Evaluate and understand the care options available to them
  • Determine what is best to meet their needs
  • Institute action to achieve their goals and meet their interests/expectations

At the same time, case managers apply:

  • Relevant state and federal laws
  • Ethical principles and standards such as the CCMC’s Code of Professional Conduct for Case Managers with Standards, Rules, Procedures, and Penalties (CCMC, 2009), which applies to persons holding the CCM® credential
  • Accreditation and regulatory standards
  • Standards of care and practice such as the CMSA Standards of Practice for Case Management (CMSA, 2010)
  • Evidence-based practice guidelines

And at every phase of the Case Management Process, case managers provide vital documentation.

Client Source

Before looking more closely at the phases of the Case Management Process, first consider what triggers the process. It begins with the identification of a client. Without a client found to be in need of case management services, there is no need to launch the Case Management Process.

The client source – that is, how case managers come in contact with clients and/or their support systems – varies based on their practice setting. For example:

  • A payor-based case manager may implement the process for a client upon direct contact via the telephone by the client/support system or upon referral from other professionals working for the payor organization, such as a medical director, a claims adjuster, a clerical person, or a quality/performance improvement specialist.
  • An acute care setting-based case manager may implement the process for a client after referral from any of the healthcare team members, including the physician, primary nurse, social worker, consultant, specialist, therapist, dietitian, or manager. In some organizations, case managers may visit every new admission and conduct a high-level review of the client’s situation for the purpose of identifying whether the client would benefit from case management services.

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The Case Management Process: Screening

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). The case manager’s objective in screening is to determine if a client would benefit from such services.

Screening promotes early intervention and the achievement of desired outcomes. Key information gathered during screening may include – to the extent available – risk stratification category or class, claims data, health services utilization, past and current health condition, socioeconomic and financial status, health insurance coverage, home environment, prior services, physical/emotional/cognitive functioning, psychosocial network and support system, and self-care ability.


The Case Management Process: Assessing

The Assessing phase involves the collection of information about a client's situation similar to those reviewed during screening, however to greater depth. This information may include past and current health conditions, service utilization, socioeconomic and financial status, insurance coverage, home condition and safety, availability of prior services, physical/emotional/cognitive functioning, psychosocial network system, self-care knowledge and ability, and readiness for change.

The case manager has two primary objectives while assessing:

  • Identifying the client's key problems to be addressed, as well as individual needs and interests.
  • Developing a comprehensive case management plan of care that addresses these problems and needs.

Additionally, the case manager seeks to confirm or update the client’s risk category based on the information gathered.

Using standardized assessment tools and checklists, the case manager gathers information telephonically or through face-to-face contact with the client, the client's support system, and the clinicians involved in the client’s care. The case manager also collects necessary information through a review of current and past medical records, personal health records if available, and communication with the client's employer, insurance representative, and others as deemed appropriate.

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The Case Management Process: Stratifying Risk

The Stratifying Risk phase involves the classification of a client into one of three risk categories – low, moderate, and high – in order to determine the appropriate level of intervention based on the client’s situation and interests. This classification allows the implementation of targeted risk category-based interventions and treatments that enhance the client's outcomes.

When stratifying a client’s risk, a case manager completes a health risk assessment and biomedical screening based on specific risk factors. These risk factors include the client's blood pressure, substance use, alcohol use, tobacco use, nutrition habits, exercise habits, blood sugar level, lipids profile/cholesterol, emotional health, physical health, access to care and utilization of healthcare services (e.g., emergency department visits or hospitalizations), psychosocial, financial (e.g., limited income, no insurance, underinsurance), and other factors, depending on the risk assessment tool/model applied. 

In some organizations, such as those that are payor-based, stratifying risks may take place prior to assessing. It also may be completed in an automated fashion using decision support systems and based on claims data. In such situations, a case manager reviews the automatically generated risk classifications and contacts the client accordingly and based on agreed upon and nationally recognized algorithms and protocols.

 


The Case Management Process: Planning

The Planning phase establishes specific objectives, goals (short- and long-term), and actions (treatments and services) necessary to meet a client's needs as identified during the Assessing phase. 

During the Planning phase, the case manager develops a case management plan of care that considers inputs and approvals of the client and the client’s healthcare providers. The plan is action-oriented, time-specific, and multidisciplinary in nature. It addresses the client's self-care management needs and care across the continuum, especially services needed after a current episode of care. 

In addition, the case management plan of care identifies outcomes that are measurable and achievable within a manageable time frame and that apply evidenced-based standards and care guidelines. Planning is completed after authorization for the health and human services to be rendered has been given by the payor source and after the services and resources needed have been identified.

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The Case Management Process: Implementing: Care Coordination

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 a client’s case management plan of care. This role is commonly known as care coordination.

During this phase, the case manager organizes, secures, integrates, and modifies (as needed) the health and human services and resources necessary to meet the client's needs and interests. The case manager shares information on an ongoing basis with the client and the client's support system, the healthcare providers/clinicians, the insurance company/payor, and community-based agencies.

 


The Case Management Process: Following-up

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. The case manager’s primary objective is to evaluate the appropriateness and effectiveness of the case management plan and its effect on the client’s health condition and outcomes. 

During this phase, the case manager gathers sufficient information from all relevant sources; shares information with the client, healthcare providers, and others as appropriate; and documents in the client’s health record the findings, modifications made to the case management plan, and recommendations for care. These activities are repeated at frequent intervals and as needed. 

Following-up may indicate the need for a minor modification or a complete change in the case management plan of care.

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The Case Management Process: Transitioning: Transitional Care

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, the case manager prepares the client and the 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, this phase’s activities entail the complete execution of the client’s transition through communication with key individuals (including sharing of necessary information) at the next level of care or setting, the client and client's support system, and members of the healthcare team. 

Additionally, the case manager educates the client about post-transition care and needed follow-up, summarizes what happened during an episode of care, secures durable medical equipment (e.g., glucose meter, scale, walker) and transportation services (if needed), and communicates these to the client, to the client's caregiver, and to key individuals at the receiving facility or home care agency (if applicable) or those individuals assuming responsibility for the client’s care.

 


The Case Management Process: Communicating Post Transition

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.

The case manager inquires about the client’s comfort with self-care, medications intake, availability of post-transition services (e.g., visiting nurse services), and presence of any issues or concerns. The case manager solicits feedback regarding the client's experience and satisfaction with services during the care episode. 

During this phase, the case manager also follows up on issues and problems identified during the post-transition communication and seeks resolution on these issues. In addition, the case manager reports the feedback gathered during the communication to key stakeholders such as payors and providers of care. Depending on the issue or concern identified, the case manager may engage other healthcare professionals to reach resolution.

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The Case Management Process: Evaluating

The Evaluating phase calls for measuring the results of implementing the 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. This evaluation focuses on several types of outcomes of care: clinical, financial, quality of life, experience and satisfaction, physical functioning, psychosocial, emotional, self-care management ability, and knowledge of health condition and plan of care. 

During this phase, the case manager generates outcomes reports such as case summary, quality, cost/billing, satisfaction, outcomes, cost-benefit analysis, and return on investment. The case manager communicates the findings or disseminates the reports to key stakeholders such as government agencies (e.g., Centers for Medicare & Medicaid Services), leadership team, client, payor, providers of care, employers, interdisciplinary team members, risk management staff, quality improvement team members, and others as deemed appropriate.

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Essential Domains of Case Management Knowledge

Although case managers practice in a variety of care settings and are from varied backgrounds, the Commission has defined seven essential knowledge domains that encompass the realm of case management work and that apply to all care settings and professional backgrounds. Each domain is further organized into subdomains.


The Seven Essential Knowledge Domains and Sub-Domains

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Case Management Concepts

The Case Management Concepts domain consists of knowledge associated with the Case Management Process, resources, and skills needed to ensure the effective and efficient delivery of safe, quality health and human services to clients/support systems. Applying such knowledge in the execution of one’s role and responsibilities as case manager enhances performance and improves productivity and outcomes. Success in the 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.

 


The Case Management Team

                                               © CCMC 2011. All rights reserved.

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The Case Management Concepts 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). 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.

Subdomains

  • Case Management Administration and Leadership
  • Case Management Processes
  • Case Management Resources
  • Case Management Outcomes
  • Regulations Related to Case Management
  • Skills and Techniques of the Case Manager
  • Communication Skills of the Case Manager

Principles of Practice

The Principles of Practice domain consists of knowledge associated with quality and accreditation, risk management, regulatory and legal requirements, ethical practices and principles, privacy and confidentiality, and overall standards of case management practice.

Subdomains

  • Quality
  • Accreditation
  • Risk Management
  • Legal Issues Related to Case Management
  • Ethical Standards Related to Case Management

Healthcare Management and Delivery

The Healthcare Management and Delivery domain consists of knowledge associated with various healthcare delivery systems and models across the continuum of health and human services and case managers’ practice settings. It also includes knowledge of case management models, concepts, processes, services, and resources. In addition, this domain addresses topics such as levels of care, transitions of care, use of standards and guidelines in the management of clients’ care, as well as collaboration among the various people involved in care such as the clients themselves, their support systems, multi-specialty care providers, community agencies, and payors.

Subdomains

  • Case Management and Processes of Care
  • Healthcare Delivery Systems
  • Case Management Programs and Models
  • Case Management Services
  • General Case Management Resources

Healthcare Reimbursement

The Healthcare Reimbursement domain consists of knowledge associated with types of reimbursement and funding systems, sources and methods, utilization review and management concepts, and roles of case managers in effective allocation and management of resources. This domain also includes quality of care, demonstrating return on investment and cost-effectiveness, and educating clients about health and wellness.

Subdomains

  • Funding Systems and Payor Sources
  • Utilization Review and Management
  • Return on Investment of Healthcare Delivery Systems
  • Balancing Quality With Its Cost
  • Education of Clients/Support Systems

Psychosocial Aspects of Care

The Psychosocial Aspects of Care domain consists of knowledge associated with the role played by clients’ cultures, values, beliefs, social networks, and support systems, as well as socioeconomic classes relevant to their health condition, ability for self-care management, and adherence to treatment regimen. This domain also includes knowledge of the case manager’s role as client advocate, legal and ethical issues relevant to case management practice, strategies for addressing issues of underinsurance or lack of insurance, clients’ education regarding health condition and treatment options, counseling and psychosocial support, and clients’ home environments and living arrangements.

Subdomains

  • Psychosocial Factors of the Client’s Care
  • Socioeconomic Factors of the Client’s Care
  • Advocacy Relevant to Psychosocial Aspects of Care
  • Clinical and Behavioral Health
  • Client Education, Support, and Counseling
  • Legal and Ethical Issues Relevant to Psychosocial Aspects of Care

Rehabilitation

The Rehabilitation domain consists of knowledge associated with clients’ physical and occupational health and functioning including vocational and disability concepts, strategies, and resources. This domain also includes 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.

Subdomains

  • Processes of Rehabilitation Care
  • Rehabilitation Resources and Services
  • Outcomes of Rehabilitation Care
  • Skills of Rehabilitation Case Managers
  • Communication in Rehabilitation
  • Regulations Relevant to Rehabilitation

Professional Development and Advancement

The Professional Development and Advancement domain consists of knowledge associated with the roles and responsibilities of case managers toward 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, curriculum development) and health or public policy work.

Subdomains

  • Value of Case Management
  • Advocacy
  • Health and Public Policy
  • Scholarship