case management has been gaining more and more recognition in recent years.¹ Significant regulatory and reimbursement changes in the health care industry have led to widespread changes in all types of health care organizations. Health care organizations have adjusted how they function, view their services, and achieve their goals. Case management is an area receiving increasing attention as payers and providers focus on coordination of care and cost containment.

With increased demand for case management services, there is a growing need for additional training and development of case managers. This course is designed to help the practicing case manager develop the skills to achieve an expert level of practice. To do this, the case manager must first understand what is happening in the health care industry. This chapter will outline key issues and concerns that are expected to drive the health care delivery system for years to come. The importance of case management will also be discussed.

Health care quality and costs will continue to be the overriding challenge for the system and for our society. The United States spends over $1 trillion — approximately 14% of the national Gross Domestic Product — on health care each year (see Table 1, “Health Care Costs in the U.S.”). Various strategies have been used to control costs, but none has proven to be sustainable; costs are expected to continue to outstrip growth in the overall U.S. economy by a sizeable margin for the foreseeable future.² Health care organizational structures and relationships have become increasingly complex. Many organizations, both providers and insurers, are financially unstable.

Table 1

Despite rising costs, the U.S. health care delivery system http://www.iom.edu/view.asp?id=5432 does not provide consistent, high-quality medical care.³ The application and use of best practices data is an ongoing challenge. There is wide variation in clinical practice. Simple interventions proven to yield the best outcomes have yet to become routine in practice. Care frequently does not meet the needs of the patient and is often not based on the best scientific knowledge.³ Preventable medical errors http://www.iom.edu/view.asp?id=5575 caused by faulty systems, processes, and working conditions cause as many as 98,000 deaths a year.⁴ In addition, the United States ranks surprisingly low (24th) on World Health Organization rankings www.who.int/inf-pr-2000/en/pr2000-life.html measuring healthy life expectancy, indicating that Americans die earlier and spend more time disabled than people who live in most other advanced countries.⁵ The health care industry will be under increasing pressure to demonstrate quality and outcomes. Regulatory scrutiny is expected to continue as the government responds to public pressure to exert increasing controls to improve quality and reduce errors.¹ Case management, along with every other segment of the health care industry, will need to demonstrate the value of what it does and show that what it is doing is achieving positive results. Case management outcomes will be covered in Chapter Three.

Demographic trends

Several demographic changes occurring in the population will affect case managers. These are the aging of the population, the prevalence of chronic illnesses, and increasing cultural diversity.

Currently 12% of the U.S. population is age 65 or older.⁶ The Congressional Budget Office projects that by 2030, 20% of the population will be 65 or older,⁷ with 2.5% being 85 years or older.⁸ The average amount spent on health care begins increasing after age 50 and rises steeply after ages 65 and 75.⁹ Twenty-seven percent of the Medicare budget is spent on care during the last year of life.¹⁰ The costs of medically futile care are enormous.

Case management will play an important role in the management of older adults to ensure that resources are managed appropriately and effectively. Involving patients and families in these decisions will help to ensure that the treatment being given is in accordance with the patient’s needs and preferences. The case manager can have a significant impact on educating, communicating, and coordinating the treatment plan, options, and decisions made.

In addition, legislative intervention is becoming more prevalent in the health care arena. Although health care issues have always been strongly influenced by political forces, a shift of power to government entities is anticipated when the majority of health care costs become publicly funded. This is expected to occur when the baby boomers begin entering the Medicare program and will provide additional incentives at the federal level for change and improvement (see Table 2).

Table 2

Public and Private Health Spending as a Percent of
National Health Expenditures

(SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary: Data from)

Patient demand will influence the medical community and the allocation of health care resources. Outcomes such as quality of life and patient satisfaction will need to be included in outcome measures. Technological advances provide the ability to prolong life and ward off illness and disease in ways that have never before been possible. Increased ethical dilemmas are expected as the public debates quality of life and cost of care issues. The case manager’s role will be instrumental in facilitating end-of-life decisions about care and increasing public awareness and education in these areas.

Another important demographic trend that will affect case managers is the incidence of chronic illnesses. Many experts feel that the United States cannot effectively address rising health care costs without addressing chronic illnesses.⁹ Chronic conditions, such as cardiovascular disease, cancer, diabetes, and lung conditions, cause major limitations in activity for one of every 10 Americans.⁹ Seven of every 10 Americans who die each year die of a chronic illness, and patients with chronic illnesses account for 75% of all health care expenditures.⁹ Thirty percent of disability cases are due to arthritis, diabetes, and respiratory illnesses.

The case management of patients with chronic illness has the potential to make a huge impact on utilization of resources, cost, and quality.² Not only are the direct costs of chronic disease high, but there are many indirect costs, such as lost work time, disability, pain, suffering, and quality of life. People with chronic illnesses cost more in any given year and cost more over time.¹¹ When chronic diseases are well managed, patients not only have lower health care costs, but they report a higher quality of life.^9,11 Keeping people healthy http://odphp.osophs.dhhs.gov/pubs/HP2000/kickbusch.htm has both individual and societal benefits. Healthy people have better job attendance and lower medical costs and are happier and more productive.^12,13 Health awareness and education have been shown to reduce employers’ health care costs.^12,13 Health plans, health care providers, and government agencies all recognize the importance of patient education in keeping people healthy. In addition, many chronic diseases are preventable through lifestyle changes and healthy behaviors. Disease management and health education are areas being targeted by employers and health plans,^9,14,15 and can be provided by case managers.

Patient education is a key goal of disease management and case management.¹⁴ The case manager can provide patient education directly and reinforce patient education done by others. The case manager can present evidence-based research and can help the patient evaluate the information found independently to be sure it is valid, reliable, and pertinent to the patient’s situation. The case manager can identify patient education needs that have not been met and facilitate additional education or a referral to other resources.

In addition to educating patients about the medical aspects of their care and recovery, case managers can teach patients how their insurance works and how to access their benefits. Case managers work with patients to explain the system and process so they can utilize their benefits as judiciously as possible to best meet their needs. The case manager help patients weigh the benefits of care and treatment options with the anticipated outcome, taking into consideration risks, lifestyle changes, out-of-pocket costs, and time involved.

A third demographic trend that has significant implications for case management is the increasing cultural diversity in the United States. Thirty-six percent of the population is from an ethnic minority, and this number is expected to increase (see Figure 1).

Figure 1

U.S. Population by Race

(SOURCE: U.S. Census Bureau; 2000.)

Case managers should be aware that gaps in both access and treatment for minorities have been consistently documented in the United States.^16,17 Recent research www.iom.edu/view.asp?id=4475 confirms that minorities have a higher death rate, are less likely to receive the most sophisticated treatments, and are more likely to undergo less desirable procedures when other options exist.¹⁸

The study also suggests that health care providers’ diagnostic and treatment decisions are often negatively influenced by patients’ race or ethnicity. Providers make inaccurate and unfair assumptions about the needs and preferences of minorities, with negative results for patients.¹⁸

Cultural competence is a new area in the case management standards of practice.¹⁹ The case manager who works with minority populations should seek out resources for understanding the special needs of these groups. Familiarity with the common customs and practices of patients from other backgrounds will help the case manager work more effectively with these patients.

Case managers must be sensitive to the needs and preferences of their patients. They should be aware of any existing biases that may influence the treatment of their patients as well as being aware of their own biases that may affect their interactions and recommendations to patients from differing backgrounds. Crosscultural education and training have been effective in increasing the health care provider’s knowledge of the cultural and behavioral aspects of health care.¹⁸ The case manager can support and facilitate this.

Case managers will need to work effectively with patients from a variety of cultural backgrounds to achieve high-quality, cost-effective outcomes for their minority patients. Case managers who are able to communicate and work effectively with culturally diverse populations will be able to achieve positive results in adherence, coordination, education, involvement, and empowerment.

There is a critical shortage of many types of health care workers in hospitals throughout the United States.²⁰ These shortages include nursing, radiology, pharmacy, laboratory, diagnostic imaging, and physical, occupational, and respiratory therapy.²⁰ In addition, nearly 60% of current nurses are over the age of 40; the increasing retirement rate of nurses is expected to collide with the aging baby boomer population and increased demand for medical care.²¹

The shortage of health care workers is expected to have an impact on the case manager. If patients are unable to get the care or services they need because of a lack of staff, this will affect the ability of case managers to get their clients the services they need, resulting in delays and access issues. If health care organizations are unable to perform or provide the services needed, the case manager will be challenged to find and arrange for the services needed elsewhere or risk delays in care.

In addition, because the majority of case managers are nurses, the nursing shortage could affect the availability of nurse case managers. Lack of qualified staff could lead to delays in service, quality concerns, and role erosion. Having ancillary staff take on some of the functions of various professionals could also result in significant changes in the health care delivery system. Case management functions could be shifted to other disciplines even as the functions become more critical than ever before.

Future success

There is much on the horizon for health care. Solutions will be challenging. Currently, there is widespread dissatisfaction and confusion among payers, providers, and patients.²² Many industry experts are recommending widespread change and an overhaul of the current system.²

Many institutions have case managers partnering with physician hospitalists or clinical teams; others assign case managers to specific physicians to build and develop a working relationship and streamline processes. Disseminating and promoting the use of evidence-based guidelines has been shown to reduce variations in practice patterns and improve health care quality.²

Physicians direct 70% to 80% of all medical expenditures and must be partners in any successful program.²³ It is vital to secure the cooperation of physicians to make and sustain changes in the system.^23,24 Case managers have been able to achieve desired goals by facilitating best practices and coordinating care after gaining the physician’s trust and cooperation. Case managers build collaboration among all parties. They  have the trust of both the payer and the provider and remain neutral and objective to achieve the goals of balancing the needs of the client, provider, and payer and acting as patient advocate when needed.

The value of coordination of care and case management throughout the continuum of care is being recognized. The improved outcomes that occur through improved coordination and efficiency as patients move from one setting to the next have been proven.^25,26 Coordination, communication, and cooperation between physicians, payers, hospitals, and other disciplines has the potential to yield unlimited gains for patient satisfaction, clinical outcomes, and efficiency and costs of care.

In addition, patients who are case managed generally report high levels of satisfaction.^27,28 Patients benefit from developing a trusting relationship with someone who is familiar with their health needs and preferences. Case managers obtain improved outcomes through their interventions of coordination, adherence, education, involvement, and empowerment of patients. These will be covered in detail in Chapter Three.

Finally, increased administrative costs are likely if government mandates and regulatory oversight increase. Until recently, the public has largely been shielded from actual health care costs. The public needs to be aware of the impact of various legislative reforms on both the financing and delivery of health care. This will allow people to make informed decisions, whether in choosing their health care coverage or voting at the polls.

Ultimately, case managers can make a difference at all levels. At the individual level, case managers work with patients and families, health care providers, and health care payers to obtain positive outcomes.

At the organizational level, case managers can assist in the development and training of new staff and mentor others. Case managers can also participate in institutional efforts to modify practice to support processes that work to facilitate communication and collaboration with others.

At the systems and societal level, case managers can identify institutional processes or physician practice patterns that are barriers to best practice for a setting and help provide information and feedback to those who are working to improve these processes. Case managers can also make an impact by participating in their professional practice organizations. These organizations represent the profession. Input and support from case managers are critical to ensure that the organization represents the needs of the group and provides leadership and support.

It is impossible to predict what type of health care system the United States will ultimately end up with, but it is clear that the most effective and efficient system will be patient-centered, well coordinated, and outcomes driven. Case managers can coordinate, navigate, and facilitate care and services regardless of what system is in place, what the process is, or who the players are. Case management is efficient and cost-effective, and produces sustainable and positive health outcomes. Organizations that utilize case management effectively will be the most successful in achieving positive health outcomes, patient satisfaction, and cost containment.

Chapter Two
Case Management Outcomes

Although exemplary results are a trademark of expert practice, case managers at any level of practice need to be able to produce outcomes. This chapter will describe five established direct outcome areas of case management. Case managers who understand how case management produces outcomes can maximize their effectiveness. By targeting areas known to deliver results, the case manager can develop plans and strategies that support the interventions that are needed.

Most case managers know what would happen without their interventions. Without case management, patients would experience unnecessary delays in care, inappropriate care, fragmented care, and duplicative care. However, the interventions and strategies used by case managers are often indirect and subtle, making them challenging to measure.

A recent national report concluded that the current health care system fails to ensure that care is appropriate, timely, and safe.¹ Another report indicated that medical errors account for 98,000 deaths annually in the United States.²

Government agencies, payers, and the public are clamoring for information to measure and compare the quality and outcomes of providers, treatments, and procedures. In addition to data that have been historically collected on morbidity and mortality, data are now being collected on hospitalization rates, lengths of stay, readmission rates, and rates of complications. Health plans are being asked to measure providers’ adherence to best practices, recommendations for preventive care and patient education, and institutional error rates. Tools to measure outcomes, such as employee productivity, absenteeism, functional recovery, and quality of life, are being developed.

Studies show that patients have better outcomes, use fewer resources, and are more satisfied with a case management program in place.³ Studies also show that a large percentage of medical errors http://qhc.bmjjournals.com/cgi/content/full/13/1/8 are due to lack of communication or miscommunication.⁴

Case management facilitates timely and appropriate care and ensures appropriate communication. As a result, case management often prevents errors, which is a powerful outcome in itself. Ongoing research is being conducted to identify and validate how and what the specific components of case management are that produce results.³

Outcome areas

The Center for Case Management Accountability (CCMA) has identified five direct outcomes produced by case management: coordination, adherence, patient education, involvement, and empowerment.⁵ These outcomes apply to all settings of case management practice and are the direct result of case management functions and interventions. The case management process and key case management functions — assessment, planning, facilitation, and advocacy — are performed with these outcomes in mind.

The five direct outcome areas of case management have a direct effect on the outcomes of the entire health system, which are quality of care (patient satisfaction), health outcomes, and cost of care. More work is being done to establish how these outcome areas can be measured, evaluated, and incorporated into practice. The results can then be used as benchmarks for case management practice.⁵

Coordination of care

Coordination of care is a direct outcome area of case management. One of the weaknesses of the U.S. health care system has been the fragmentation and lack of coordination between providers, systems, and agencies.² Lack of coordination results in poor health outcomes, lower quality of care, and increased costs. The lack of coordination within the health care system causes delays in care, prolongs treatment and recovery times, compromises patient safety, and wastes resources.²

Coordination of care has been established as a key function since the beginnings of case management, in the early 1900s.⁶ Case managers coordinated services in the public health sector for returning veterans. Since then, case management has been used to coordinate care throughout the public and private sectors in all health care settings, including provider, payer, and community agencies.

Today, case managers must help patients navigate through increasingly complex health systems and processes. Services are fragmented, systems are complex, and many providers are overworked, rushed, and lack the resources they need to complete their work. In addition, the continually changing and increasingly complex regulations in health care confuse even the most experienced practitioner. The case manager has to coordinate the care within payer structures and reimbursement limitations to achieve the most effective and efficient outcome.

Patient adherence

Another direct outcome area of case management is patient adherence. Adherence is defined as the extent to which a patient’s behavior coincides with medical or health advice that constitutes a treatment plan for a given condition.⁷ This can include attending appointments, taking medications as prescribed, and following diet or activity restrictions, or making other lifestyle changes. Adherence is also known as compliance. Factors that influence adherence include understanding of instructions, access to resources, and environmental, financial, or cultural barriers.

A clear link exists between patient adherence and the effectiveness of health interventions.^8,9 Patients who follow the recommended treatment plan for their course of illness recover faster and more completely. This results in higher quality of care, improved patient satisfaction, and reduced costs.^8,9

Studies show that nonadherence is widespread among all diseases and populations.¹⁰ Suboptimal adherence contributes to increased costs of care, health outcomes, and decreased quality of care in many diseases, including cardiovascular disease, pulmonary disease, diabetes, mental health, and epilepsy.¹⁰ Suboptimal adherence is a potential public health hazard in the treatment of communicable diseases.¹⁰ Patients develop wound infections, fail to heal, and reinjure as a result of not following instructions. Procedures have to be redone; there is prolonged hospitalization or rehospitalization, increased disability, and increased costs. This results in secondary complications, failed treatment or procedures, and poor outcomes.¹⁰

Patients with chronic illness have repeated hospitalizations and complications as a result of not following recommended care.¹⁰ People with diabetes who do not maintain adequate control of their blood glucose have frequent hospitalizations and develop serious complications, such as kidney failure, peripheral vascular disease, and diabetic retinopathy.¹⁰ Chronic wounds, amputations, dialysis, and blindness are common outcomes of poorly managed diabetes. The results are increased disability, increased care needs, and a poorer quality of life.

An ongoing objective of the case manager is ensuring that patients follow through with their treatment plans. The case manager works closely with patients and families to ensure they understand what they are supposed to do, and why, and to ensure they are in agreement. If there are problems, the case manager intervenes to eliminate or minimize them.

Knowledge, involvement, power

The remaining direct outcome areas are patient knowledge, involvement, and empowerment. These three areas are presented together because they are so closely linked and use the same interventions.

Numerous studies have shown the importance of providing information to patients and involving patients in their own care.¹¹ Patients who are knowledgeable and involved in their care obtain better outcomes and report higher levels of satisfaction.

A patient’s knowledge level affects his or her ability to follow instructions, adhere to the treatment plan, and make the best decisions about care. Patients’ knowledge of their benefits and coverage and how to access resources is also important. Studies show that patients who are knowledgeable about selecting and evaluating their care receive better quality and service.³ Case managers provide information to patients and families on how to access and utilize their benefits and how to navigate the system. This will become increasingly important as patients are asked to make more choices about their physicians, hospitals, and health plans.

Empowerment is defined as “to give power or to enable.”¹² Knowledge and involvement empower patients.¹³ The degree to which patients feel empowered contributes to their ability to manage what is needed, or their self-efficacy.¹³

Self-efficacy is one’s belief and confidence level in being able to accomplish what one is being asked to do. Studies of patients in weight loss or smoking cessation programs indicated that the more strongly the patient believed in his or her ability to accomplish their goal, the more likely they were to be successful.¹⁴ The higher the self-efficacy, the more likely the patient will achieve his or her goal. Therefore, patients who believe in their ability to learn a new skill or have an impact on their health are more likely to achieve this.¹⁴

Case managers work tirelessly with patients to ensure that they have the information and resources they need. Case managers involve the patient and the patient’s family in as much of the patient’s care as possible. Case managers empower patients by enabling them to make informed decisions.

Interrelationships

Although there are specific case management strategies and interventions for each of the direct outcome areas, the success or lack of success in any one area can have strong implications for another. Each of the areas can affect the other areas positively or negatively. Therefore, the expert case manager proceeds with all areas in mind, mindful of the effects of one area on another. A positive result in one area can enhance what is needed in another area at just the right time. Likewise, neglect in one area can have ramifications on another area, and the case manager can be prepared for this.

For example, scheduling appointments (coordination) is much easier if the patient is following the plan (adherence). Patients are more likely to be willing to follow the plan (adherence) if they understand what is needed (knowledge) and have agreed to it (involvement).

Patients who understand what they are supposed to do (knowledge) and participate in their care (involvement) are more likely to follow their treatment plan (adherence) and make informed decisions (empowerment). A patient who is experiencing ongoing delays and confusion (lack of coordination) may become frustrated and decide to stop following the treatment plan (nonadherence). These are all examples of how these outcome areas are linked.

Data

Being able to measure outcomes will be essential in demonstrating and communicating the value of case management to organizational decision makers. Many organizations are developing tools to measure case management outcomes, as well as to determine caseloads and evaluate programs and processes.¹⁵ Case managers will want to be comfortable with the technological tools that are available and use them to enhance and support their practice. Case managers need to be seen as early adopters of technology, willing to pilot new systems, embracing new tools and information to see if they will work, and modifying them as needed to capture what is needed for new systems to work.

Organizations need case managers to help develop evaluation tools that capture the direct outcomes of case management. Technology can be valuable for collecting, analyzing, and reporting large amounts of information. Technology can also be used to share information quickly and accurately. In addition, technology can be used to streamline processes so they support essential case management activities.

Automating routine tasks will provide the case manager more time for assessments and patient interactions. Many organizations are exploring ways to expand case management functions to incorporate evidence-based practice, quality measures, and quality improvement.¹⁵ Technology can maximize and support case management interventions, improve efficiency and continuity, and reduce errors.¹⁵ Case managers who participate in these activities will be able to obtain information pertinent to their work and use it to identify opportunities for improvement as well as potential solutions.

Case management prevents complications, poor outcomes, and prolonged disability and eliminates duplication and harmful delays. Case mangers can maximize their effectiveness by focusing on strategies that coordinate care, improve patient adherence, increase patient knowledge and participation, and empower patients. These are the interventions that produce positive health outcomes, improved quality of life, and reduced costs.

Chapter Three
Levels of Practice: from Novice to Expert

This chapter will present five levels of practice for case managers. These levels are presented to provide a guide for those who want to identify where they are in their own practice and those who wish to progress to the next level. This information will also be useful to those who train case managers.

The levels of practice presented here are adapted from Pat Benner’s work with nurses in which Benner describes five distinct levels of practice for nursing professionals.¹ These practice levels were originally identified in an extensive study of skill acquisition in chess players, pilots, automobile drivers, and adult learners of a second language.² Benner found these to apply to nurses as well.²

The five levels of practice exist on a continuum and range from rule-guided practice to experienced know-how. Although typical timeframes are given for each level, these are used as a general reference only. The defining factor for each level is the description of practice at each level.^1,2 For example, the expert is defined by the exemplary results obtained, not the number of years of experience.^1,2

The five levels of practice are novice, advanced beginner, competence, proficient, and expert.^1,2 Each level of practice will be described and discussed in relationship to case management practice.

Novice level

The first level of practice is the novice level. A novice follows steps.^1,2 The novice is learning all aspects of the job, including the core knowledge specific to his or her setting of practice. The core knowledge areas include processes and relationships, health care management, community resources and support, service delivery, psychosocial intervention, and rehabilitation case management. The novice is learning what is needed for that particular job and patient population. For example, knowledge areas for a community-based case manager working with elderly patients would include Medicare benefits, resources for home health care, and services offered at local senior centers.

Novice case managers also need to learn the steps of the case management process. The case management process consists of assessment, planning, implementation, coordination, monitoring, and evaluation activities. The novice needs to learn what is involved in a typical assessment, what the case manager is expected to do, and the timelines for common case management interventions and activities. Novices may rely on checklists or forms to assist them in completing common tasks.

In addition to learning the case management process and specific knowledge areas, the novice develops skills in key areas that are needed to perform case management effectively. Key case management skills include critical thinking, communication, negotiation, collaboration, and advocacy. The case management process, key skills, and core knowledge areas are covered in the course Case Management Basics.³

Novice case managers are not yet able to prioritize or multitask and will perform the case management functions sequentially, completing one step at a time, often following strict rules and regulations.^1,2 Often, novices cannot proceed to the next task until the task at hand is completed. They typically require extensive information before initiating an action. They are unable to sort out pertinent information from extraneous information and will spend substantial time gathering information and making informational inquiries. Novices need step-by-step instructions or guidance and get stuck if something does not go as planned.

Advanced beginner level

The next level is advanced beginner. Advanced beginners are comfortable with the typical activities and scenarios that occur in their practice setting. They are familiar with the core knowledge areas generally encountered in their practice setting, such as local resources, benefits and coverage, and the referral process for services commonly used. However, complex or atypical issues are often brought to their attention only after a problem surfaces.

Advanced beginners are able to begin reflecting on how things went to create a process that will work in the future. They are beginning to prioritize and multitask.^1,2 They are beginning to recognize situations that involve patient advocacy issues and legal or ethical concerns.

Competence level

The next level of practice is competence. The case manager at this level functions independently, handling most tasks and situations with ease but still gaining in speed and flexibility. Competent case managers are able to prioritize and multitask and can plan and organize their workdays.^1,2 Competent case managers are familiar with the normal diagnoses, timeframes, and activities that occur in their population and setting and initiate the appropriate interventions for both typical and atypical scenarios. If there is a change, the case manager is able to problem solve.

The competent case manager has developed the skills in negotiation and collaboration that are necessary to be effective. This case manager is a skilled communicator, interacting effectively with patients, families, physicians, and other case managers.^4,5 He or she works well with patients and families, meeting them at their level, gaining their trust and confidence, and respecting their goals, values, and preferences.⁶

The competent case manager working with specific populations is sensitive to their special needs, which may include cultural factors. Cultural factors can determine how treatment decisions are made, who the decision maker is, how information is communicated, and caregiver roles. For example, some cultures, such as in the United States, place a high value on work, and individuals develop a strong identity and sense of purpose from their jobs. Other cultures emphasize family relationships and pride in those roles.⁷ The case manager working with populations with special needs has developed a feel for the characteristics of the group and can recognize these and respond appropriately.

The case manager functioning at the competent level is well grounded in the fundamentals of case management and feels very comfortable in his or her practice. The case manager is knowledgeable about the core areas that are pertinent in that setting and can identify patient advocacy and legal and ethical issues as they arise.

Many case managers continue to practice at the competent level for long periods of time. However, competence must be maintained as knowledge and skills can quickly become outdated in a continually evolving field such as health care. The case manager must stay up-to-date on the clinical treatment and outcomes for frequently encountered diagnoses, as well as the resources in the community, service providers and access, and regulatory changes that affect benefits and coverage. The case manager who does not work to stay up-to-date is at risk for becoming stagnant and ineffective.

The competent case manager can continue to develop additional skills and expertise and progress beyond the competence level. As in any profession, speed and efficiency increase over time and as expertise is developed.^1,2 However, expertise is not just an accumulation of experiences, but is the deepening perspective, character, and judgment that evolves as the case manager approaches new situations with openness and attentiveness.² The expertise that is developed over time is based on experience and past outcomes that allow the case manager to apply the appropriate judgment and decision making to the context of each situation that is encountered.¹ This insight is what transpires as the case manager progresses to a more advanced level of practice.

Proficient level

Following the competence level is the proficient level. Case managers function at the proficient level when they know what typical events to expect and can recognize when the normal picture does not materialize,^1,2 enabling them to be proactive and intervene early. The case manager knows what aspects are the most salient at the moment and identifies problems right away.^1,2 The case manager may no longer adhere to strict rules, knowing when exceptions are appropriate.^1,2

The case manager functioning at the proficient level is comfortable being flexible and creative.^1,2 This case manager is a strong critical thinker and creative problem solver. The proficient case manager takes a broad and holistic view of the situation when addressing unusual or unique situations. The case manager inquires and probes where needed, exploring additional and less-known options when appropriate.

The proficient case manager recognizes a variety of cues based on experiences and knows when to take action, whether creating or initiating an action or creating a reaction. These can be key decision points or turning points in a patient’s recovery. Examples of these include a patient’s readiness to learn a skill, a family’s readiness to address a patient’s prognosis, or a patient’s readiness to make a treatment decision or disclose crucial information. The case manager knows when to push and how much. The case manager can also sense when there is trouble.¹

For example, one well-known decision point occurs when a patient is ready to return to work. Studies show that there is a window of opportunity for a successful return to work.^8,9 This window occurs when a patient is physically and psychologically prepared to return. Psychological, social, and emotional factors play a big part in the recovery of patients with work injuries, and mistrust and fear can quickly escalate and prevent effective treatment and recovery.^10,11 The case manager working with injured workers must evaluate the patient’s readiness to return to work, prepare the patient for return to work, and facilitate this at the appropriate time. If a patient does not return to work during this time, the chances of a successful return lessen the longer this does not occur.⁹ Patients often lose confidence and become fearful of reinjury, making a return to work increasingly difficult.^11,12

Key decision points also occur when patients are ready to learn a new skill, look at their operative site, or move to the next level of independence. Patients who are prevented from progressing when ready become frustrated and discouraged, which can lead to significant delays and barriers to their recovery.

The proficient case manager has developed systems to facilitate efficient workflow and streamline routine tasks. The proficient case manager is able to evaluate outcomes and can identify practice patterns among frequently used providers. The proficient case manager is comfortable and confident handling typical advocacy and legal and ethical issues and consults others when appropriate. The case manager functioning at this level has established strong working relationships with others and can bring in others with the appropriate expertise when needed.

Expert level

The final level of practice is the expert level. At the expert level, the case manager no longer consciously uses rules and principles, but instead quickly focuses on what is relevant and intuitively chooses the appropriate action and response.^1,2 The expert case manager has mastered the key skills of case management and performs the case management process seamlessly with maximum effectiveness and efficiency. The case management process is smooth and streamlined, with the case manager continually intervening when appropriate to minimize or prevent problems.

The case manager functioning at the expert level is able to quickly grasp the situation at a holistic level and then zero in on what needs to be done, even in the most complex situations.^1,2 The expert case manager is a critical thinker, continually searching for alternatives, modifying and evaluating, and looking at new ways of doing things if the current way is not working. The expert case manager functions in a proactive mode, identifying problems early and intervening to minimize their impact.

Expert case managers pick up on subtle cues and choose the appropriate response and action. They keep alternatives in mind and leave options open so that changing course midstream can occur with minimal disruption. Only when things don’t go as planned or when a new situation arises do  experts resort to analytical problem solving; otherwise decisions are made based on feel.¹ They make rapid decisions, move quickly, and prioritize what needs to be done and when.^1,2 They persist with problem solving until the issues are resolved.⁵

Expert case managers are strong in all the core knowledge areas, even those that may not directly relate to their setting of practice. They use well-developed knowledge in the core knowledge areas to work with all parties involved. A hospital-based case manager who has an awareness of general rehabilitation concepts will be more effective in addressing issues surrounding return to work and disability and the impact of these on the patient’s treatment and recovery. Likewise, regulatory changes for home care agencies are useful information for a hospital-based case manager even though the changes do not apply directly to hospitals. The case manager who is aware of the changes will be more prepared for any indirect impact the changes may have on the hospital.

An understanding and appreciation of other settings of practice also enable the case manager to work effectively with case managers and health care professionals in other settings. The case manager continually evaluates new information and new programs and routinely consults with colleagues in case management as well as those in other fields when appropriate. This lets the case manager stay current on the latest developments and trends.

By the time the case manager has reached the expert level, his or her credibility and reputation are known among colleagues and within the community. This can provide much needed support when support is difficult to find. The expert case manager has a strong sense of patient advocacy and is able to identify when patient rights are being overlooked. The expert case manager works proactively to prevent legal and ethical and advocacy issues and is routinely sought after by colleagues and other health care professionals for advice. The case manager advocates for the patient when needed — whether to lobby for care or services or to educate the patient about realistic options or resource limitations.

Experts are described as the ones who handle anything you can throw at them and seem to always figure out a way to get things done, even if it isn’t necessarily what anyone had planned.^1,2 Colleagues recognize experts for the remarkable results they obtain.^1,2 Although longevity is not the determining factor for reaching the expert level, the expert level cannot be achieved without significant experience.^1,2

Once a case manager has achieved the expert level of practice in one setting, expert practice in other settings can occur quickly.¹ Case managers who move from one practice setting to another could achieve expert level in the new setting once well versed in the core knowledge areas unique to their populations and settings. The case management process and key skills are universal and remain the same for all practice settings.

Case management is dynamic and ever changing, with ongoing challenges. Case managers must be able to use a variety of approaches to work in the different situations that arise. Case managers continually develop clinical knowledge, skills, and expertise in their area of practice. Although obtaining exemplary results is a trademark of expert practice, case managers at every level should be able to produce outcomes. While some of the characteristics and interventions described at the expert level are also performed at other levels, the expert has mastered these.

All case managers, even those at the expert level, continue to grow and develop. Although not all case managers are expected to achieve the expert level, only by knowing what expert practice looks like can one work toward it. It is hoped that the information in this chapter will help case managers enhance their practice wherever they are on the continuum.

This discussion of expert practice is not meant to imply that every case manager can or should be at this level. It takes time and experience to achieve the expert level. This discussion is also not meant to portray the expert level as an unattainable ideal. Experts’ decisions don’t always work out.² However, understanding what expert practice looks like can be valuable for case managers practicing at any level.

Leadership

With the increased demand for case management services there comes a growing need for additional training and development of case managers.³ Inadequate training and lack of supervision and resources can prevent new case managers from doing their jobs effectively and can lead to professional burnout.^13,14 Clarity about role function and goals and how to achieve these is critical for case managers to achieve effective practice.

As case managers develop expertise, they will be in an ideal position to take on leadership roles. The case manager who manages a caseload and improves case management practice is a role model for other case managers and the rest of the team.⁶ Case managers acting as mentors are an invaluable resource and support for newer case managers.

Leadership is also needed to educate other health care professionals about the role of the case manager. Case managers can provide leadership to the health care team by guiding them in best practice and outcomes-driven care. Case managers who can articulate their roles will be able to increase awareness and understanding of case management’s role and its value.

Case managers at all levels should be familiar with the practice standards for their profession. The Case Management Society of America has developed numerous resources for case managers. The definition and standards of practice for case managers were published in 1995 and revised in 2002.¹⁵ The ethical standards were published in 1996.¹⁶ In addition, many organizations have developed or are developing certifications and competencies for case managers.

Chapter Four
Understanding the Legal Issues and Risks in Case Management

Knowledge of legal issues and their potential impact is necessary for the case manager to practice effectively. Without this knowledge, the case manager cannot perform with confidence. Whether legitimate or unfounded, fear about liability can become a distraction, hindering critical thinking and becoming a barrier to appropriate practice. Case managers need to be aware of the legal issues they are most likely to encounter and the potential ramifications of their actions so they can minimize risks and prevent actions that could result in unintended consequences.

This chapter will explain the elements of malpractice. Areas of legal risk will be described as well as what the case manager can to do to minimize the risks. Roles and responsibilities of the case manager will be described along with strategies for protecting against legal actions.

Elements of malpractice

Case managers can be held liable for malpractice just as any other health care professional can be.¹ Malpractice is the violation of a professional standard of care that results in injury to a patient.¹ The case manager has a duty to meet the standard of care for case management.

In order for a case manager to be successfully sued for professional malpractice, the elements of malpractice must be proven. These four elements are duty, breach of duty, injury, and causation.¹ If any of the elements are missing or cannot be proven, there will not be a successful malpractice claim¹ (Figure 2).

Figure 2

Elements Required for Professional Malpractice

Duty means that there was an understanding that the case manager had taken on the responsibility for the case management of the patient, either by having accepted the assignment or having an established relationship with the patient during the time of the occurrence.¹

Once duty has been established, it has to be determined that the case manager has breached that duty.¹ Breach of duty means that the case manager failed to meet the standard of care. This could involve an act of commission (the case manager did something he or she shouldn’t have) or an act of omission (the case manager did not do something he or she should have).² For example, the case manager may have carried through with an intervention that was known to be contraindicated and harmful to the patient. This would be an act of commission. An act of omission would occur if the case manager had failed to provide key information to the physician that would have resulted in a different treatment decision being made.

Whether a breach occurred is determined by comparing the case manager’s actions to the standards of care for the profession, taking into account any community variances.³ This could include testimony from peers as to what they would have done or been expected to do in a similar situation. The case manager’s actions would be compared to what another reasonably prudent case manager would have done or would have been expected to do.²

In order for a successful malpractice claim to exist, an injury must have occurred.¹ The injury must also be proven to have been a direct result of what the case manager did or did not do.¹ Therefore, even though mishaps occur and errors are made, if an injury does not occur as a direct result of the case manager’s action or inaction, the elements for a successful malpractice action do not exist.

Implications for case managers

To minimize the risk of liability, case managers need to follow the standards of practice for the license they hold as well as the standards of practice for case management.¹ For example, a nurse case manager would need to adhere to the standards of practice for both nursing and case management. The same would apply to physicians, social workers, and others performing case management; each of these disciplines has a defined scope of practice that is governed by their state practice boards. The standards of practice for various types of professional practice are available from the licensing or credentialing boards for those professionals.¹

The standards of practice for case managers were developed by the Case Management Society of America and are widely recognized and used throughout the health care industry.⁴ Case managers need to be familiar with these standards just as they would be with the standards of practice governing their license. These standards will be used to determine whether a case manager performed competently.

Besides professional practice standards, case managers need to follow organizational policies and procedures and the expectations outlined in their job description.⁵ Job descriptions that define roles and scope of practice can be used to show whether a case manager did or did not do what was expected.¹ However, simply following organizational policies and procedures may not protect the case manager if the policies clearly violate established standards of practice and the case manager was aware or should have been aware of this. If the job description or organizational policies conflict with the professional standards of practice, the case manager needs to alert his or her organization of the discrepancy so it can be rectified.

Areas of risk for case managers who work in managed care organizations include contracting and credentialing, required notifications, dispute resolution, and the process and timeframes for appeal.² The case manager needs to adhere to organizational processes that were designed to ensure that the organization is in compliance with these laws and regulatory requirements. Areas in which organizations have been held liable include breach of contract, wrongful denials, bad-faith conduct, failure to follow procedures for ensuring that contracted providers are licensed and competent, and failure to notify patients in a timely manner of their rights to appeal a decision.²

Managed care organizations often make decisions about coverage. If the managed care organization determines that a particular treatment or service is not covered, the patient is entitled to a timely decision, an explanation of the decision, and information about his or her rights and the process by which the patient can appeal the decision if desired.² Case managers should be aware of their role in ensuring that this information is given to the patient. Case managers should also remember that whether or not something is covered does not preclude patients from going ahead with the treatment independently if they choose to do so.

The risk of liability involving eligibility decisions and determinations is generally low, but the risk involving treatment decisions is not.¹ Treatment denials should always be made by a physician or medical director. Even though the case manager does not make these decisions, case managers can be held liable if they have knowingly provided outdated, incorrect, or incomplete information or misrepresented the information that resulted in an incorrect decision being made.^2,3

There has recently been a focus on fraudulent processing and payment of claims to providers. In addition, federal and state laws are focusing on areas such as Medicare compliance.⁶ Many organizations are dedicating significant resources and time to ensure that their billing practices meet the criteria necessary to avoid the appearance of fraudulent billing.

Laws have been passed requiring providers to disclose any financial ties to referrals being made, any financial factors that could influence their decisions, and the process by which they notify patients of their rights to appeal decisions.² Many states have a regulatory agency to conduct third-party arbitration when all steps of the appeal process have been completed and the dispute continues. Some health plans require binding arbitration; others allow patients to go to court for a final resolution.²

A case manager can be sued for acting in bad faith if the case manager was biased and acted in a punitive way toward the patient or unreasonably delayed a process or intentionally derailed a plan.³ Case managers responsible for facilitating or coordinating authorizations could be exposed to risk if their actions or inactions caused a delay in treatment that resulted in harm or death.^2,3 When there is an untoward event, the courts look at whether the parties involved acted in good faith and did what they were supposed to do in a reasonable fashion and timeframe.

New and emerging areas

Other areas of risk emerging for case managers involve confidentiality and consent.¹ In the past, case managers assumed they had the patient’s consent in the absence of a directive or refusal, but this is no longer presumed.

The new case management standards require that case managers obtain written or oral consent for their services.⁴ They should obtain consent during the first contact.

The case manager introduces himself or herself and the case manager role and asks permission to work with the patient. The case manager may share his or her plan and interventions with the patient and ask whether the patient agrees with them. This can be accepted as implied consent and should be documented. If the patient is a dependent or minor or has legal representation, the appropriate person should be contacted.

Some organizations may develop written consent forms for a more formal consent. In some settings, consent for case management services is included in the consent for treatment. Some organizations and health plans include the consent as a condition of participation in that health plan. The case manager should be aware that consent can be removed at any time should the patient change his or her mind, and the case manager should pursue any concerns about consent if a patient is uncooperative or openly hostile to the case manager’s contacts.

Case managers should disclose any financial incentives that could influence their decisions and recommendations, such as ownership in a program that may be recommended as a treatment option.² These same disclosures apply to physicians who have ownership in laboratories or surgery centers to which they refer patients.

Some have claimed that financial incentives that managed care organizations give to physicians may lead them to deny treatment to cut costs.⁷ Physicians are precluded from withholding information about treatments that may be appropriate simply because they are costly or uncovered.² Health care providers should disclose to patients any financial ties that could influence the recommendations they make. Money or gifts from others in exchange for referrals is considered a kickback and is illegal.³

Case management services may be terminated by the patient or family, payer, case manager, or others. This could occur when goals are met, when there is a change in health care setting or a loss of benefits, if the case manager is no longer able to perform or provide appropriate case management services, or when the patient withdraws consent.⁴

If the case manager terminates the services, he or she should inform the client, health care team, supervisor, and others involved with reasonable notice. Depending on the circumstances, the case manager should document the decision and the rationale for the decision.⁴ The patient and health care providers can be informed verbally or in writing if necessary. To terminate services without notification could constitute abandonment.

Patient privacy is another key issue in health care. The case manager is bound by laws and regulations that concern patient confidentiality and the disclosure of personal medical information. Recent patient privacy legislation (HIPAA) www.hhs.gov/ocr/hipaa/finalreg.html requires that the release of information not used specifically for treatment, payment, or health care operations is subject to specific authorization from the individual.⁸

All hospitals, clinics, physician offices, and insurance companies are required to have reasonable safeguards to protect personal medical information from those who should not have access.⁸ Health care organizations must have protections in place for the electronic submission and transfer of information.

Faxing and e-mailing medical information must be done carefully. Senders should always send to a designated person, and receivers should receive the information in a way that does not expose the material to others who do not need the information. Voicemails and e-mail accounts need to be password protected.

The law also requires special consent for the disclosure of sensitive information, such as information about psychiatric treatment, HIV status, and sexual abuse as a minor.⁸

The patient can refuse to give consent at any time. But there may be adverse consequences, and the patient should be made aware of this. For example, if a patient refuses to allow pertinent information to be given to the payer, there is a possibility that the payer will not pay for the care.

While case managers have an obligation to protect the personal health information of patients, they also have an obligation to disclose certain types of information.¹ Some types of information are subject to mandatory reporting, such as actual or suspected child or elder abuse, criminal acts or specific knowledge of threatened harm to another person, and certain communicable diseases. The right to privacy does not apply to any mandatory reporting required by law.¹ Case managers need to be aware of the specific mandatory reporting requirements in their state.

Strategies for minimizing risk

Protocols and standards of practice can offer legal protection. An example is a  malpractice action that involved a telephone advice nurse who provided  instructions to a pregnant woman who had called in with cramping and discharge and ultimately delivered a premature infant that did not survive.¹ The court found that the nurse had followed protocols, that the protocols were developed according to generally accepted standards of practice, and that no malpractice occurred. The nurse had given the appropriate advice and instructions, and the patient had not called back to notify of any further problems before going to the ED.¹ Protocols and guidelines and how they are developed are important and provided this nurse with protection.

Documentation is essential to minimize legal exposure.^1,5 If legal action is taken, what is or isn’t documented can help or hurt the case manager. Without adequate documentation, the case manager may not be able to demonstrate that protocols were followed.

The case manager should include notes about patient consent, information, and interventions. Documentation should include the dates and times of calls, names of people spoken to, and the information conveyed.¹ All entries should be signed by name and title.

If any decisions are made, the notes should include the patient’s agreement and/or options given. The case manager should note any failures to follow instructions and any attempts or interventions made to correct or assist. Patient complaints or disagreements should include the case manager’s interventions and attempts to resolve them, the reaction to them, and further plans.^1,5 The case manager should avoid terms that are judgmental, derogatory, or otherwise biased.¹ Instead, document actions taken even if there is no response, and describe the behaviors, not the conclusion.

Case managers must comply with all laws, including those that give patients the right to make informed decisions and refuse treatment.¹ Case managers can be held legally accountable for personal acts, such as altering records, misrepresenting information, restraining a patient without consent or justification, forcing a treatment or intervention despite the patient’s refusal, or stopping a treatment without appropriate consent.¹

Case managers should make it clear to their patients that they cannot participate in any illegal or fraudulent activity, and if they have any knowledge of this, they are obligated to report it. Case managers are also obligated to report anything they feel is needed to serve the patient’s best interests or prevent harm to another person and any mandatory disclosures. This is important to explain up front when a patient asks to disclose something in strict confidence or asks for secrecy.

Finally, communication and communication style are key (Table 3). When something goes wrong, patients are more likely to sue if they feel they have been treated badly.⁵ This has long been known for cases involving physicians, RNs, and other health care providers. It also applies to case managers.

Table 3

Staying up to date with national, professional practice, and community standards is critical for the case manager.¹ Case managers must be aware of what is happening in the quickly changing industry and regulatory environment of health care. Case managers should network in the field to learn about and discuss common issues and concerns. This allows case managers to stay current with developments in the industry and the norms and practices of colleagues. Professional organizations and industry publications also are effective ways to stay up to date on current practices.

Chapter Five
The Case Manager’s Role in Ethical Dilemmas

Case managers must understand their role in ethical dilemmas to ensure appropriate practice. Studies show that many health care professionals working in case management experience significant role confusion and angst.^1,2 The case manager often interacts with others who have conflicting interests and can feel torn between clinical and financial pressures. New case managers struggle with role ambiguity and conflict as they learn the job.¹ Clarity about the case manager’s role in ethical dilemmas is important to ensure appropriate practice and to manage job stress.¹ Case managers can also function in leadership roles by guiding others when ethical issues arise.

This chapter will cover the basic ethical principles and the most common ways to approach ethical issues. The role and responsibilities of the case manager will be discussed along with steps that will help the case manager work effectively in these situations. Case managers who are familiar with the ethical principles and have a framework for analyzing ethical dilemmas will be better prepared to handle these when they arise.

Ethical dilemmas

Ethics is the study of standards of conduct, and ethical behavior is behavior that conforms to the standards of conduct of a given profession or group.³ An ethical dilemma is a situation in which there is a conflict of values. There is no clear consensus about what is right or wrong and no single, generally acceptable code of behavior that everyone can agree on.¹ Ethical dilemmas often create a general feeling of unease and lead to sleepless nights wondering if the right decision was made.

Debates on fetal tissue research, genetic testing, and euthanasia all have ethical components. Opinions differ about what is right or wrong; what is beneficial for one group may be harmful for another. Concerns about health care costs have resulted in discussions about technological advances and whether their impact on quality of life justifies their costs. Family members as well as health care professionals may disagree on how much treatment is appropriate. These are common ethical dilemmas in health care.

Once the case manager is aware of an ethical concern or issue, efforts can be made to obtain the information needed and to explore options. To be effective, the case manager must remain objective and facilitate communication and resolution of the dilemma. If left unresolved, these dilemmas can lead to frustration and conflict among all involved. They often result in gridlock and end with a poor patient outcome.

Ethical principles

Five basic ethical principles are widely recognized and can be applied to case management.^2,3 These are autonomy, justice, veracity, beneficence, and nonmaleficence. Each principle is equal but can be given different weight in different situations. An ethical dilemma exists when two ethical principles conflict and a decision between two or more equally principled choices must be made to resolve the situation.¹

Autonomy, or freedom, is the principle by which we function when we ask patients what they want, obtain informed consent, or allow them to refuse care or sign out against medical advice.^2,4 Autonomy is a strongly held value in the United States. U.S. culture emphasizes independence and the rights and freedoms of the individual.⁵   In other cultures, fairness, or justice, may be highly important and take precedence over individual freedoms.⁵ The emphasis is on what will be the most fair for the group as opposed to any one individual. Decisions are made based on the greater good or what will produce the most good for the most people.^2,4

Two other ethical principles are beneficence and nonmaleficence. Beneficence is defined as being of benefit or promoting good.⁴ Nonmaleficence means doing no harm.⁴ These two areas are routinely considered when the options for treatment are discussed with a patient or family. The potential benefits of the treatment are explained along with the possible risks. Health care providers routinely consider the benefits and risks before making a recommendation for treatment.

Decisions about treatment options for patients with a terminal illness and end-of-life care revolve around beneficence and nonmaleficence. A practitioner who is looking at the benefits of a procedure will practice very differently from one who is trying to avoid doing harm.

The fifth ethical principle is veracity, or telling the truth.⁴ Most people experience an ethical dilemma involving veracity  when deciding whether or not to tell the truth when doing so may be hurtful or have other negative consequences. Balancing what or how much to tell is an ethical dilemma.

Veracity is an ethical dilemma when patients choose not to let their families know their prognosis. In some cultures, it is not acceptable to share a poor prognosis with the patient as this will destroy hope, which is believed to cause death.⁶ Both of these situations can create emotional distress for the practitioner and the case manager.

Approaches to ethical dilemmas

In addition to the ethical principles, there are three common ways in which most people approach ethical dilemmas.² Being familiar with these will give a case manager a better understanding of how people approach these situations and how this influences their actions and decisions.

One approach is known as the paternalistic approach.⁷ This is when a person or group designates someone as the decision maker. The decision maker can be one person, such as the boss or a judge, or a group, such as a medical panel or a religious institution.⁷ A patient who says, “The doctor knows best” or “It’s up to Dr. Jones” is using this approach. These patients willingly relinquish decisions to their physician. Some cultures designate a certain family member for this role. Physicians who automatically assume that they know what is best for the patient are using a paternalistic approach.⁷

Another common approach is to extend a principle or opinion and apply it to the situation at hand without regard for the consequences. People using this method act solely on a moral principle or opinion. This is known as the deontological approach.² For example, an animal rights activist will argue against a medical treatment because the research involved animals. This approach looks only at the primary principle and does not consider any consequences of the decision, such as how the research was done, whether the treatment is expected to be successful, or what will happen if the treatment is not done.

A third way of looking at ethical dilemmas is to consider the common good, or what is best for the most or least advantaged people. This is the utilitarian approach.⁸ This is at the heart of discussions about how health care resources should be distributed, who should get what, what should or shouldn’t be covered, and why.

Insurance plans making decisions about how to structure their benefits to provide for the needs of the most people in a fiscally responsible way are using the utilitarian approach. A decision to provide coverage for thousands of childhood immunizations instead of an organ transplant for one patient would be an example of the utilitarian approach.

Case manager role

The case manager’s role in an ethical dilemma is to work cooperatively with everyone to get a resolution.^1,9 The case manager must be able to identify the ethical issues and facilitate a dialogue about the pros and cons of various options with all parties to reach consensus if possible. If no consensus is possible, the case manager clarifies the final decision and moves forward with a plan. See Figure 3 for the recommended steps to take when dealing with ethical dilemmas.

Once an ethical conflict has been identified or comes to the attention of the case manager, he or she obtains information from all parties about the issues. The case manager identifies the pros and cons of each option from the point of view of the patient, provider, and payer and the ramifications of each choice.

Figure 3

If institutional policies and procedures or legal issues are involved, the case manager obtains their parameters and implications. Once clear about the options and the consequences of each, the case manager communicates with all parties to see if there is consensus on what to do. If there is, the dilemma is resolved and the plan moves forward.

If further discussion is needed, a meeting is scheduled to present the dilemma to the patient. The family or others can be and should be included if appropriate. In some instances, a group conference may be the best forum.

If the decision is about medical treatment, the physician may be the appropriate person to present the information to the patient or family. The case manager can facilitate this. The patient should receive information about the timeframe in which a decision is needed and whether there is any urgency or consequences if a delay occurs. The patient should be offered assistance and access to additional resources if available.

Once the information has been presented and explained to the patient, the case manager can meet separately and repeatedly if needed with the patient to go over the options, the rationale for each, and the consequences or ramifications of each. The case manager can arrange for additional meetings, consultations, or whatever else may help the patient make an informed decision.

All information should be presented to the patient. The case manager should ensure that the patient has every opportunity to get all the necessary information to make an informed choice. If the patient is a competent adult, he or she has the right to make the ultimate decision. The case manager can help the patient analyze the choices, balancing the pros and cons and weighing the arguments to come to an informed decision.

It is important to  respect the patient’s right to choose. The case manager must remain objective, being careful not to impose personal values or judgments on the client.^9,10

The case manager must not become overly sympathetic with a client or develop a personal friendship with a patient, provider, or payer as this can have the appearance of a bias or conflict of interest. The case manager must act in a way that is uncontaminated by personal gain, fear of reprisal, or other ulterior motives.¹¹

Although each ethical principle is equally important, to resolve a dilemma one principle will need to be given precedence after careful consideration of all the principles and circumstances.¹ This is done only after careful analysis and input from the people involved.

There may be varying opinions on how to resolve the dilemma, depending on the people involved and their personal preferences and values. People will have personal opinions about which principle is most valued in any given circumstance, and people make decisions based on which principle is most important to them. The case manager analyzes all the angles and tries to facilitate the option that is best for the majority of those involved.

Case managers should be familiar with and respect other perspectives to be effective in working with patients who may be operating from a different perspective or approach. Case managers should evaluate their own personal preferences and values so they are aware of how they may be influencing their professional practice and whether this is appropriate. If needed, the case manager can seek additional information and resources or consults with others.

Once a decision is made, the case manager makes sure it is communicated through the appropriate channels and carried out respectfully. The patient then needs to receive adequate support and case management follow-up. If the case manager finds that he or she cannot  adequately perform the case management role, he or she needs to arrange for alternate resources or for the case to be transferred to another case manager.⁹

Common ethical dilemmas

One example of an ethical dilemma involves a 25-year-old woman with major trauma from a car accident who is refusing blood transfusions because of religious beliefs but has a steadily falling hematocrit. Although the patient is competent and legally has the right to make the decision to refuse the transfusions, this can create an ethical dilemma for the medical providers as they watch the patient worsen. The initial dilemma is autonomy vs. beneficence, then autonomy vs. nonmaleficence as the hematocrit drops into a dangerously low range that will result in death if not reversed.

In this situation the case manager’s role is to ensure that the patient is given appropriate information about the potential seriousness of the situation and the consequences of the decision while she is still able to make an informed decision. The case manager assists in clarifying any areas of conflict or concern and facilitates whatever is needed and appropriate for the patient to make an informed decision and communicate it effectively. Family and friends may be involved if the patient permits.

Another ethical dilemma involves a 52-year-old patient with severe decubitus ulcers who insists on going home despite serious misgivings from the staff, his family, and the insurance company. The ethical principles are autonomy vs. nonmaleficence. The dilemma is that allowing the patient his choice (autonomy) will result in serious harm, likely infection, contractures, sepsis, and death (nonmaleficence).

The case manager makes sure the patient is aware of the concerns of the various health care professionals and the ramifications of the action. If the patient decides to go home, the case manager works to ensure that home support is arranged and leaves the door open for the patient to return.

Many ethical dilemmas for health care professionals revolve around end-of-life issues, what constitutes comfort care, who gets to decide, and when and with whom to share a grave prognosis^12,13 (see Table 4). Case managers are often involved in these discussions with the family. 

Table 4

A 37-year-old moderately disabled woman repeatedly aspirates because she insists on eating even though she has a feeding tube because she cannot swallow effectively. In the past the patient has required short periods of intubation for treatment of her aspiration pneumonia. She has indicated that she does not want to be intubated, and this is consistent with her behavior of trying to pull out her tube when it is in place, which then requires her to be in restraints.

How much autonomy does a disabled person have, and how can a determination be made about whether the patient truly understands the consequences of his or her choices? Can a moderately disabled person be expected to comprehend that not having the tube will result in death? Or, if the tube is placed, is this causing distress and affecting quality of life so as to violate the patient’s rights? These are all examples of the kinds of questions and discussions that occur when ethical issues are present.^11,12

Case managers may have ethical dilemmas surrounding authorization of care issues and the allocation of health care resources, as influenced by financial factors. Is a discharge safe? Who gets to decide? When does a health care professional or case manager override this, or should they? What can or should be done when a patient continues to make poor choices? What role does the case manager play? What responsibilities does the case manager have?

Other topics the case manager will face involve the ongoing debate about health care resource allocation: Who should get what, and how is this decision made?^12,13 Is health care a privilege or a right? Is it fair to punish unhealthy behaviors with “sin taxes,” such as those for alcohol and tobacco? Some have suggested a tax on high-fat foods. Where do we draw the line?

Those who work with patients with long-term care needs and chronic illnesses will face issues involving who has decision-making capacity, who should be the surrogate, the role and responsibilities of family and friends, and safety vs. neglect.¹²

Responsibilities

Case managers must take an active role in the debates, at a personal level with family and friends or professionally with colleagues and other providers. Not to do so will jeopardize practice and affect performance and morale over time. A study of nurses showed that those working in an environment in which they felt they were behaving unethically suffered from anger, fear, powerlessness, and guilt.¹⁴ The nurses responded by avoiding negative situations and disengaging from work.

Case managers can initiate and facilitate thoughtful discussion about the ethical dilemmas surrounding health care. Engaging in meaningful dialogue will bring these issues to the public’s awareness so that others can be more prepared for these situations when they arise.

Case managers need to be aware of their personal preferences and values so they do not impose these inappropriately on others. This will minimize barriers when working with others who may have different values and beliefs. The case manager needs to maintain a nonjudgmental approach to be effective. Understanding the inherent biases and motivations of others can be useful to identify a mutual goal. Learning to recognize and resolve ethical dilemmas produces feelings of greater professional autonomy, allows better management of moral distress, and reduces the likelihood of burnout.^15,16

Case managers must use resources such as professional organizations, colleagues, supervisors, peer review, medical ethics committees, community ombudsmen, universities, courses, and consultants to keep up-to-date on ethical issues. This will help the case manager deal with ethical issues on a personal, professional, institutional, community, and societal level. With increasing visibility in the current economic and political landscape, case managers will be at the core of issues in the health care debate as society struggles to balance care and cost.

Chapter Six
Case Study: an Expert in Action

The following case study is an example of expert practice. It describes and analyzes the characteristics of expert practice and how a case manager uses the core knowledge and key skills of case management throughout the case management process. This will be followed by a discussion of legal and ethical situations that can be applied to the case study.*

Joe, a 63-year-old Hispanic man, was not making progress with his rehabilitation program after a complex fracture of his right wrist. He had also developed frozen shoulder because of a lack of mobility. According to the physician’s reports, Joe was not following through with the exercises and home program the physical therapists provided. Several therapists had tried working with Joe, including one who spoke Spanish. But this had not seemed to make a difference. The therapists reported that they had to go over the same instructions with Joe on each visit and that he did not seem to be able to demonstrate the exercises he had been given despite all their instructions. Joe did not appear to be motivated to return to work, and they speculated that he might be just waiting to retire since he was near retirement age. Joe worked on an assembly line and had been off work since his injury several months ago.

The case manager met with Joe in his home. He was married and had 10 children ranging in age from 5 to 21. The case manager observed Joe’s wife and his daughters and sons diligently helping Joe with his ADLs. They brought Joe food and drink, and anticipated his every need.

Joe was becoming frustrated with his lack of progress. He understood the importance of doing the exercises and insisted that he was doing them as instructed. Joe reported that in the past several weeks his wrist had become more stiff and painful, and was now becoming swollen. When asked about his work plans, Joe indicated that he was not yet ready to retire and hoped to return to his job. 

Because of Joe’s symptoms and the appearance of his hand, the case manager suspected reflex sympathetic dystrophy and arranged for a consultation with a specialist in chronic pain/RSD. The diagnosis was confirmed. The physician and case manager met with Joe and his family to explain the diagnosis and treatment. Joe would undergo a series of injections to block the nerve pain. In between injections, he would be required to participate in strenuous exercises of the fingers and hand to regain normal function. The family agreed to allow Joe to do his own care as this would be an important way for him to progress and would be part of his rehabilitation.

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