Principles of Case Management
Case Management Toolbox

 
 
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Standards of Practice for Case Management
Dr. Dawn-Elise Snipes PhD, LPC-MHSP
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox and Case Management Toolbox

CEUs are available at https://www.allceus.com/case-management-toolbox-podcast  Get two free months of Therapy Notes by using the promocode CEU when you sign up for a free trial at TherapyNotes.com

– Based in part on the Standards of Practice for Case Management by the Case Management Society of America
Objectives
– Explore the benefits of adding case management to your skill set
– Learn how Case Management is financially beneficial
– Explain the principles of case management
– Identify practice settings
– Review risk factors (targets) for case management

Why Case Management-
– Adjunct to clinical practice
– Enhances coaching and clinical services
– Can be its own business (High copay/high deductible)
– Understanding capitation
– It pays the doctor a set amount for each enrolled patient whether a patient seeks care or not.
– Compensation is based on the average expected utilization of each patient in the group.
– 100,000 people 20% expected to need 10 sessions of brief therapy @ $45/session 20,000*450= 900,000/year
– Use it or lose it caveat

How Case Management Reduces BH Cost
– Ensures wrap-around services (i.e. housing, transportation, medical care, public assistance)
– Better health –> Better mental health
– Improved health literacy – Better mental health
– Reduced stress (financial, interpersonal, occupational) –> Better mental health
– Treatment plan compliance – Better mental health
– Nonfragmentation of services –> Better mental health
– Guidance during service transitions – Better treatment compliance –> Better mental health
– Advocacy with community leaders for funding service gaps- improved service access – better mental health
– Case managers are less expensive than licensed providers

Case Management Principles
– It can be applied to individuals or groups of clients, such as in disease management or population health services.
– Underage drinking or STD prevention at universities
– Diabetes, heart disease, premature birth prevention (Clinical or foundations)
– Cancer, diabetes, depression, autism management (Clinics or foundations)
– Ageing services (AAA, geriatric physician groups, LTC & STC facilities)
– The goal is achieving client wellness and autonomy through advocacy, communication, education, identification of service resources and service facilitation.
Case Management Principles
– Services are best offered in a climate that allows direct communication between the case manager, the client, and appropriate service personnel
– When an individual reaches the optimum level of functioning, everyone benefits: the client(s), their support systems, health care delivery systems, reimbursement sources, communities.
Case Management Process
– Assess client resources, needs, goals
– Collaborate and Plan – Identify service plan goals and needed resources
– Implement
– Monitor
– Evaluate
Primary Case Management Functions
– Positive relationship-building
– Effective written/verbal communication
– Negotiation skills
– Knowledge of legal, ethical and risk management issues
– Cultural responsiveness
– Ability to develop goals, enhance motivation and evaluate progress
– Promotion of client autonomy and self-determination
– Knowledge of funding sources, health care services, human behavior dynamics, health care delivery and financing systems, and clinical standards and outcomes
Guiding Principles
– Use a client-centric, comprehensive, holistic approach.
– Facilitate self-determination and self-care with advocacy, collaboration, and education.
– Remain culturally responsive
– Promote the use of evidence-based care
– Enhance client safety
– Link with community resources.
– Assist with navigating the health care system
– Maintain competence in practice.
– Promote quality outcomes and measurement
– Support and maintain compliance with federal, state, local, organizational, and certification rules and regulations.
Degrees of Complexity
– Varies based on the following four factors
– The context of the care setting, such as wellness and prevention, acute, or rehabilitative.
– The health conditions and needs of the patient population(s) served, as well as the needs of the family/caregivers, such as critical care, asthma, renal failure, hospice care.
– The reimbursement method applied, such as managed care, workers’ compensation, Medicare, or Medicaid.
– The health care professional discipline designated as the case manager, such as registered nurse, social worker, physician, rehabilitation counselor, etc.
CM Practice Settings
– Hospitals
– Long and short term care facilities
– Outpatient clinics
– Student health centers
– Corporations
– Health insurance companies
– Private case management companies
– Jails
– VA
– Community behavioral health
– Geriatric facilities and practices
– Hospice
– Medical group practices
– Life care planning organizations
– Disease management companies
Roles and Functions
– Conducting a comprehensive assessment of the client’s health and psychosocial needs, including health literacy status and deficits, and develops a case management plan collaboratively with the client and family or caregiver.
– Planning with the client, family or caregiver, the multidisciplinary team, the payer, and the community, to maximize quality, and cost-effective outcomes
– Facilitating communication and coordination to minimize fragmentation in the services.
– Educating the client, caregivers, and team about treatment options, resources, benefits, psychosocial concerns etc., so timely, informed decisions can be made.
Roles and Functions
– Empowering the client to problem-solve by exploring options of care to achieve desired outcomes
– Encouraging the appropriate use of health care services and improving quality of care and maintaining cost effectiveness
– Assisting the client in the safe transitioning of care
– Striving to promote client self-advocacy and self-determination.
– Advocating for both the client and the payer to facilitate positive outcomes for all involved
Advocacy
– Promotion of the client’s self-determination, informed and shared decision-making, autonomy, growth, and self-advocacy
– Education of other health care and service providers in recognizing and respecting the needs, strengths, and goals of the client
– Facilitating client access to necessary and appropriate services through education and advocacy
– Recognition, prevention, and elimination of disparities in accessing care and outcomes
– Advocacy for expansion or establishment of services and for client-centered changes in organizational and governmental policy
Client Selection
– Duration client has had the diagnosis
– Level of pain control
– Functional status (ADLs) or cognitive deficits
– Previous home health and durable medical equipment usage
– History of mental illness or substance abuse, suicide risk, or crisis intervention
– Chronic, catastrophic, or terminal illness
– Social issues such as a history of abuse, neglect, no known social support, or lives alone
– Repeated treatment admissions
– Need for admission or transition to a post-acute facility
Opportunities for Intervention & Goals
– Lack of established, evidenced-based plan of care with specific goals
– Over-utilization or under-utilization of services
– Use of multiple providers/agencies
– Use of inappropriate services or level of care
– Non-adherence to plan of care
– Lack of education or understanding of:
– The disease process
– The current condition(s)
– The medication list and/or provider treatment plan
Opportunities for Intervention & Goals
– Medical, psychosocial, mental health and/or functional limitations
– Emotional & cognitive needs: Counseling, medication
– Physical needs: Sleep, nutrition, housing, co-occurring physical conditions, safety
– Social needs: Social support, interpersonal skills, child or respite care
– Vocational needs: Job coaching, accommodations, employment or meaningful activity
– Financial needs: Housing, utilities, medication, food, transportation
– Environmental needs: Transportation

Opportunities for Intervention & Goals
– Patterns of care or behavior indicating worsening of the condition.
– Inappropriate discharge or delay from other levels of care
– Frequent transitions between settings
Case Manager Qualifications
– Current, active, and unrestricted licensure or certification or baccalaureate or graduate degree 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
– *Case managers assess needs and resources and may screen for mental health, physical health or addictive disorders
Summary
– The demand for case managers is growing rapidly as insurance companies restrict reimbursement, move toward capitation and as individuals with high copays try to reduce expenses.
– Not only are case managers employed by hospitals and treatment centers, but increasingly by organizations like businesses and universities that have a strong motivation to keep their employees/students healthy and (relatively) happy
– Case managers provide assessment, advocacy, education and assistance with treatment coordination and implementation, often in a multidisciplinary team
– Case managers do not diagnose or treat illnesses