This chapter is a revised version of what was previously published in the first edition of CMSA Core Curriculum for Case Management. The contributor wishes to acknowledge Patricia M. Pecqueux, as some of the timeless material was retained from the previous version.

A. Case management is an interdisciplinary practice that focuses on the coordination of the care activities and the allocation of resources required by a patient during an acute or non-acute episode of illness.

B. A case manager manages, facilitates, and coordinates the necessary care activities and treatments, applying an approach to care delivery that is called the case management process.

C. The case manager also manages communication among the varied care providers and other essential parties internal and external to the health care organization.

D. The case management process focuses on the identification of patients who would benefit from case management services, and the activities of assessment, problem identification, care planning, care delivery, monitoring, and evaluation of the care provided, specifically for its relevance to the needs of the patient/family, and for the health care team’s ability to meet the desired outcomes and established goals.

E. Each patient is unique, and the case management process takes into consideration the individual needs of the patient, family, and caregiver. This is not only limited to the patients’ medical condition and treatment; rather, it includes their financial and psychosocial state, as well as their culture, values, and belief system.

F. Each case manager has her or his own unique style of case management based on one’s own experience, education, skills, knowledge, ability, creativity, specialization (e.g., critical care, organ transplantation, rehabilitation, home care), professional discipline (e.g., nursing, social work, rehabilitation counselors, workers’ compensation specialists), and professional networks.

G. The case management process is a set of steps applied by case managers in their approach to patient care management. It is similar to the nursing process (and other processes used by other disciplines such as social work and medicine).

H. The case management process has been applied in the care of a select group of patients based on certain criteria determined by the health care organization. These criteria are the necessary factors that indicate the patient’s need for case management services.

I. Some activities of the case management process may vary significantly based on the case management setting (preventive, pre-acute, acute, post-acute or managed care, ambulatory, hospital, community, home, skilled facilities, and so on) and the population served (pediatric, geriatric, behavioral health, and so on).

J. Through the case management process, case managers eliminate fragmentation and/or duplication in care delivery. They also maintain open and timely communication with all parties involved in care in an effort to ensure continuity, safety, quality, and cost-effective outcomes.

K. The case management plan designed by the case manager in collaboration with the patient, family, and other health care providers identifies immediate, short-term, and ongoing needs, as well as where and how these care needs can be met.

A. Advocacy—According to the Commission for Case Manager Certification (CCMC), advocacy is “acting on behalf of those who are not able to speak for or represent themselves. It is also defending others and acting in their best interest. A person or group involved in such activities is called an advocate” (CCMC, 2005a, p. 18).

B. Assessment—The collection of “in-depth information about a client’s situation and functioning to identify individual needs and in order to develop a comprehensive case management plan that will address those needs. In addition to direct client contact, information should be gathered from other relevant sources (patient/client, professional caregivers, nonprofessional caregivers, employers, health records, education/military records, etc.) (CCMC, 2005b, p. 5).

C. Collaboration—Working together with the client/family, care providers, and other agents who are both internal and external to the health care organization for the purpose of achieving consensus on the case management plan and to maximize care outcomes (CMSA, 2002).

D. Continuum of care—“The continuum of care matches ongoing needs of the individuals being served by the case management process with the appropriate level and type of health, medical, financial, legal and psychosocial care for services within a setting or across multiple settings” (CCMC, 2005a, p. 3).

E. Coordination—“Organizing, securing, integrating, modifying, and documenting the resources necessary to accomplish the goals set forth in the case management plan” (CCMC, 2005b, p. 6).

F. Discharge planning—“The process of assessing the patient’s needs of care after discharge from a health care facility and ensuring that the necessary services are in place before discharge. This process ensures a patient’s timely, appropriate, and safe discharge to the next level of care or setting, including appropriate use of resources necessary for ongoing care” (CCMC, 2005a, p. 4).

G. Evaluation—“Determining and documenting the case management plan’s effectiveness in reaching desired outcomes and goals. This might lead to a modification or change in the case management plan in its entirety or in any of its component parts” (CCMC, 2005b, p. 6). This activity is repeated at appropriate intervals and is adjusted or changed as necessary based on the plan and the client’s condition.

H. Facilitation—An activity assumed by the case manager to promote communication among the client/family and the health care team members including the insurer. Facilitation also focuses on collaboration among all parties to achieve the case management goals and to ensure informed decisions (CMSA, 2002).

I. Implementation of the final plan—Linking the patient’s assessed needs with private and community services, filling the gaps in care and services, avoiding duplication of services, and obtaining agreement on the plan of care from the patient and his or her support systems. The main goal in these activities is maximizing the safety and total well-being of the patient (Powell, 2000).

J. Implementation—“Executing and documenting specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan” (CCMC, 2005b, p. 6).