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 development 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/​StandardsOfPract​ice.​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 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:

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 managers 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.

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 programs. The screening criteria generally include medical and psychosocial considerations 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.

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 educators can present information in an understandable was, noting the health literacy level of families, to make sure families are able to participate as informed consumers understanding their choices in care decisions.