Chapter 1 - What Is Case Management? 

Case management and managed care sound similar, and many people assume they are the same. They are not. Case management is a process that has been practiced since the early 1900s.¹ Managed care is a system of healthcare delivery and financing initiated in the 1970s in response to public concern for escalating healthcare costs.² This course will focus on the practice of case management and its roles and functions.

Background, development

The practice of case management has been around for more than 70 years. In the public health setting, nurses and social work case managers have provided resource coordination for social programs, community services, and war veterans. In the insurance setting, case management has been practiced by nurses, vocational counselors, and rehabilitation specialists to facilitate patients’ maximum medical recovery and return to gainful employment after catastrophic injury.¹

In the 1980s, nursing case management was instituted in acute care institutions in response to the DRG (diagnosis related group) payment method to coordinate services and provide discharge planning for hospitalized patients.² Case management is now used in inpatient, outpatient, community, and payer settings. The expansion of case management into more settings — coupled with the increasing demand for these skills — has prompted other healthcare professionals such as physical and occupational therapists, admission coordinators, physicians, and administrators to assume case management roles and responsibilities.

The case management model and professionals selected to perform case management depend on the populations served and the types of services provided. Patients with medically-complex issues need a case manager with clinical expertise. A social services agency whose primary role is to coordinate resources may use social work professionals. A job retraining program that works with employees with disabilities may use vocational experts to perform case management responsibilities. Some agencies use a variety of healthcare professionals with different backgrounds for a team approach to case management; others use healthcare professionals as needed to consult on specific aspects of cases. In addition to primary case management, nurses can supplement a case manager or work as part of a multidisciplinary team to carry out case management activities.

Definition

Case management is defined as care coordination and advocacy for specified patients and patient populations across settings to reduce cost, reduce resource use, improve quality of health care, and achieve desired outcomes.³ The Case Management Society of America defines case management as a collaborative process that assesses, plans, facilitates, and advocates for options and services to meet a patient’s health needs through communication and available resources to promote quality, cost-effective outcomes.¹ (See Table 1.)

Case management is recognized as a practice that can be performed by professionals with varying backgrounds. However, nurses may be uniquely qualified to be case managers because of their holistic and broad-based background, understanding of health care, and role in patient education and referrals.⁴ Case management is an area of practice that offers nurses an opportunity to build on their clinical knowledge, communication, and nursing process skills to function in an expanded patient care role.

Goal of case management

The goal of case management in healthcare settings is to obtain positive health outcomes by ensuring well-orchestrated, coordinated care. Because case management has been shown to reduce medical costs significantly in patients with disabling illnesses and injuries,⁵ managed care organizations have added case management as a cost-containment strategy.

Case management reduces overall costs by avoiding costs associated with medical complications that can be prevented and result in poor health outcomes. It can also reduce societal costs associated with prolonged disability and chronic illness. A patient with foot ulcers who develops gangrene and needs an amputation not only suffers personally, but incurs additional healthcare costs for treatment, including medical appointments, surgery, rehabilitation, prosthesis, supplies, home health care, and long-term care.

Case management also saves money when it eliminates unnecessary or inappropriate care or treatment and reduces duplication, overbilling, or system inefficiencies that cause costly or harmful delays. Case management achieves positive outcomes through patient education, information, advocacy, and empowerment.⁶

The case manager works closely with the patient and patient care team to create a plan that not only meets the patient’s needs, but also is acceptable to all involved. To obtain agreement and support from all parties can be the most challenging task for the case manager. In some settings, patients are asked to provide written consent before case management services can begin. In others, consent is implied but can be withdrawn at anytime, which limits direct patient contact and the effectiveness of case management services.

Case management works best with the patient’s input and cooperation. Many medical treatments require the patient’s participation to be successful, and patients who are involved in their treatment often obtain the best outcomes. Most patients respond favorably to a case manager who treats them respectfully and facilitates their role in the recovery process. Case managers who establish a rapport can coach and guide patients toward desired outcomes. Case managers who work with patients from diverse cultural backgrounds need to learn the nuances of those cultures to establish rapport.

Case managers must promote and support the patient’s wellness and independence; to create or contribute to dependence is detrimental to the long-term health of the patient.⁵ For example, to obtain an electric wheelchair may not be helpful for a patient who is expected to achieve independent ambulation. To arrange for excessive home care assistance or support the activities of an overprotective family member may also have a negative effect on a patient’s recovery.

The case manager must recognize a patient’s own level of responsibility and accountability in his or her care, and both respect and demand it. The case manager works with all parties to remove obstacles that prevent or discourage the independence of the patient, hinder access to needed services, or prevent the patient from making informed choices. Case managers are advocates for patient education, information, choice, and accountability, which lead to patient empowerment.

Case management activities

The six essential activities of case management are assessment, planning, implementation, coordination, monitoring, and evaluation.⁷ The case manager performs these activities while working with the patient and family, healthcare providers, healthcare delivery system, payer of services, and community. Although the role and focus of case managers may vary from setting to setting, the essential activities remain the same.

Case managers use the knowledge and skills from their training and experience to perform the essential activities. Knowledge of case management concepts, principles, and strategies is needed along with knowledge of healthcare systems for delivery and reimbursement. The case manager also needs knowledge of the population and setting, and the resources available in the community. Key skills needed include critical thinking, communication, collaboration, negotiation, and advocacy.  These areas will be covered in greater depth in the next few chapters.

Chapter 2 - Essential Activities 

The case management process consists of six essential activities: assessment, planning, implementation, coordination, monitoring, and evaluation. Case management practice uses critical thinking, communication, negotiation, collaboration, and advocacy to apply these six essential activities to the three areas of knowledge case managers use to carry out their roles.

Assessment

A thorough assessment forms the foundation of a good plan. The assessment process gathers pertinent information about a patient’s situation and ability to function to identify needs and develop a comprehensive case management plan.¹ The time to gather information will vary — in some cases, a few phone calls may be enough to obtain the key information needed to begin. In other cases, the case manager may need several hours to review records, call physicians, or meet with the patient.

The type of assessment depends on the patient’s medical condition, the goal of case management, and the urgency of the patient’s needs at the time of the referral. The case manager obtains information from the referral source about issues and concerns. The assessment of a patient injured on the job includes a functional assessment of what the patient can and cannot do, his or her essential job functions, and an occupational history. To prepare an elderly patient for discharge, the case manager assesses for ambulation, the ability to manage daily living activities, and home safety.

The assessment can include physical findings, a patient interview, medical reports, and information from others, such as family, friends, employer, and other care providers. The case manager evaluates the information sources for reliability, credibility, and potential bias. The case manager’s goal is to obtain accurate information about the patient’s status and identify factors that may significantly affect the patient’s recovery and care.

Case managers rely on medical reports and documents from other providers for information on clinical findings and diagnostic results. They must be able to identify normal and abnormal findings and test results, and determine when more information is needed. It is also essential they know the history and course of the problem, how long symptoms have existed, what has been done, and which treatments were effective. This information can be obtained from medical reports, by phone, or in face-to-face meetings. In some practice settings, case managers may perform a physical exam as part of their role.

Case managers who meet with the patient can obtain valuable information through observation and interviews. The case manager can also obtain information about the patient’s daily routine, functional limitations, receptivity to various treatments and approaches, and home and work environments.

The case manager must identify other factors that may affect the recovery or treatment of the primary problem. These include age; other medical conditions; use of medications; psychological, mental, emotional, or social factors; lifestyle; and family influences. The case manager assesses the patient’s and family’s understanding of the diagnosis and expectations of the prognosis. The case manager’s professional knowledge, experience, and communication skills help to identify normal and abnormal coping patterns, family dynamics, and potential barriers to recovery.

Medical records and reports from various sources provide an overview of the case as well as the treatment to date. Results of diagnostic studies are essential; operative reports may also be useful. The physician can be contacted to confirm the diagnosis, treatment plan, and prognosis, and to clarify information. Because medical reports are limited, it is strongly recommended that all pertinent information in the reports is validated with the patient or other reliable source. Reports from other healthcare  professionals, such as physical therapists and counselors, as well as reports from the patient and family can corroborate the sequence of events and reports of others.

Other helpful information includes home support, physical and environmental barriers, occupation, educational level, accessibility to resources and support, past experience with health care, previous accidents, learning barriers or preferences, language barriers, the patient’s goals and expectations, and any fears or frustrations or other issues that may affect recovery. The more information obtained, the more thorough the assessment; however, it is not necessary to have every report in the file. In the interest of time, the case manager must select the areas of highest priority, then continue to collect information as the plan is implemented and evaluated. The assessment continues throughout the case as new information becomes available and changes occur.

In some settings, an initial screening is performed to identify patients who are most likely to benefit substantially from case management services and interventions. Those patients are then referred for case management. Factors that would lead to a referral for case management include age, diagnosis, social factors such as homelessness or complications of illness, multiple or dual diagnoses, or repeated hospitalizations. (See Table 1.) The screening tool to identify potential candidates can be manual or computerized.

Planning

The planning process sets up specific objectives, goals, and actions to meet identified needs.¹ The case management plan is action-oriented and time-specific. The level of detail and duration of the plan depends on the case objective and priorities. The goal may be to return a patient to work, prepare for a complex surgical procedure, facilitate a safe discharge, manage a chronic illness, project lifelong care for a quadriplegic, or coordinate hospice care for a dying patient. The case manager considers the patient’s medical condition, psychological status, social support, and realistic expectations about what case management can accomplish.

A plan for an 80-year-old female with a fractured hip who lives alone could include a three-day hospital stay, a four-week stay in a subacute facility with intense rehabilitation services, and then four weeks of home care physical therapy and attendant care.

If a patient is hospitalized, the case manager’s first priority is to evaluate the clinical status and appropriate level of care. A safe discharge and home management plan can then be developed. For a patient who needs a second surgical procedure, the case manager prepares ahead of time for the procedure to ensure the patient is ready physically and psychologically.

The case management plan should include specific actions and the steps, sequence, duration, and frequency of interventions. The plan is based on the case manager’s knowledge and experience with the normal rehabilitative course expected, and takes into account the patient’s unique characteristics and situation.

It is ideal to have the patient’s full cooperation; however, the case manager must also confirm that the plan is feasible and agreeable to everyone involved. This confirmation may require verification with providers that certain services are available, with payers that services are covered and fall within the guidelines for authorization, and with family members to determine whether they are able to take an active role. When the plan is confirmed, the case manager explains the details to the patient to procure his or her agreement and cooperation.

In some cases, a plan must be implemented without the patient’s cooperation.  The case manager can still develop a framework or skeleton of the overall plan, even though the plan is likely to change. This framework ensures that the plan is focused and goal-driven. A patient may prefer to delay a procedure to take care of personal issues; however, this may not be medically feasible or acceptable to the insurer. The case manager determines whether this is a reasonable option and what the ramifications are to all involved. In other cases, a patient may insist that his or her return to work is impossible, yet the case manager still works earnestly with the employer and physician to explore options for a return-to-work plan. Monitoring and decision points occur more often when plans are implemented without the full cooperation of all parties.

Implementation

The case manager should implement the plan as quickly as possible. If time is limited, the case manager can implement the first step of the plan and modify the plan later if needed. The case manager initiates action when needed and functions as the change agent. Providers must be contacted to discuss the plan and confirm their part in the intervention. The case manager facilitates care, removes barriers to care, and ensures access to services. The case manager may also need to arrange transportation, coordinate scheduling of providers, and deal with language and cultural barriers.

Patients must be involved during implementation of the plan so they can prepare for changes and transitions in care. A case manager encourages compliance when his or her patient teaching reinforces instructions from care providers and provides other relevant information. In some hospitals, patients receive a patient guide as a personal care map that tracks their progress.²

Coordination

The case manager organizes, secures, integrates, and modifies the resources necessary to accomplish the case management goals.¹ This involves the patient, physician(s), and any health or social service professionals and agencies that provide services, as well as family members and friends involved in the patient’s care. The case manager is responsible for the smooth and efficient follow-through of the plan.

The case manager routes and sends pertinent information to those who need it. When the desired information is identified, the case manager sends it to the appropriate person, confirms that the information was received and, when needed, confirms that follow-through has occurred. For timely delivery of the information, the case manager calls, faxes, mails, copies, and even delivers key information to ensure that it is available to the appropriate person.

The case manager ensures that diagnostic tests do not interfere with other treatments and are done at appropriate intervals. The case manager follows up on test results and ensures they are provided to the physician in time for follow-up with the patient.

The case manager follows up with the physician periodically to discuss the plan, any changes, and any other issues. This follow-up can be by phone, letter, or face-to-face and will depend on the physician’s style, patient’s preference and ability to communicate, and type of information. Based on these discussions, the case manager will incorporate changes as appropriate and proceed with the plan.

The case manager keeps outside parties up-to-date and communicates with the claims representative to ensure timely authorization and smooth claims handling. The case manager contacts those who are affected by the changes and sets up a schedule to monitor the new plan to check that goals remain appropriate. In cases where many services are provided at the same time or multiple providers are involved, coordination can make the difference between timely, efficient care and chaos.

Federal privacy legislation known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides clear parameters on the type of information that can be shared and with whom.³ Information for purposes of treatment, payment, and healthcare  operations (TPO) can be shared freely with providers and payers for those purposes. In fact, case managers need to provide the information required to facilitate appropriate continuity of care and continued treatment from one setting or provider to another as well as provide the information that satisfies payer requirements to authorize needed services. However, information for other purposes, such as marketing, research, and sharing information with a patient’s friends or family, requires a separate specific consent from the patient. Case managers must ensure that they have specific consent from patients before they share any information for non-TPO purposes.

Case managers should also ensure they follow appropriate safeguards to protect confidential patient information; this information includes any data that identifies a particular patient. This protection applies to the storage and disposal of documents and their careful handling so others do not have haphazard or accidental access to identifiable health information of others. For example, medical reports should not be left in public-access areas and should be shredded when discarded. Case managers should also make reasonable efforts to verify the identity of those they share information with and exercise caution when personally identifiable health information is shared electronically or by facsimile. Use cover letters that indicate the information is confidential, designate to whom it is sent, and provide instructions on what to do if it is received in error by someone other than the intended recipient.

Privacy regulations apply to many healthcare  settings, including hospitals, medical offices, health plans, and vendors. To comply with regulations on electronically transmitted information, most institutions have built in information technology security devices, such as firewalls, to ensure that computer screens are password protected; these institutions also have limited electronic access only to those screens that contain the information needed. Case managers who transmit information electronically will need to ensure that the information does not contain personally identifiable data or that firewalls are in place to protect from unauthorized or unintended access.

Monitoring

To monitor a care plan, the case manager gathers pertinent information from various sources at regular intervals to determine compliance and progress.¹ Checkpoints can occur daily, weekly, or monthly and can be with patients, providers, or family members. These checkpoints ensure that the treatment plan is followed and everyone is on track. If a patient’s progress is less than expected, the program may not be a good fit or care may be hindered by other factors. Monitoring allows early identification of problems and immediate adjustments if the patient is not progressing as planned.

Each person is unique; therefore, each case is unique. Monitoring is done as often as appropriate based on the specific needs of the case and its progress. Monitoring intervals will depend on the speed and amount of progress, frequency of reports from other sources, and timing of key decision points. A patient who lives alone may need more frequent monitoring than one with constant family supervision.

The case manager monitors progress from the patient’s perspective, the amount of functional improvement, symptoms, medications, understanding and compliance with home instructions, and changes since the last contact. The case manager contacts the provider regularly to obtain a progress report and an updated plan, and to identify any changes or areas of concern. For example, if a patient has missed appointments, the case manager can intervene right away.

Even when the case’s progress is smooth, maintenance monitoring should occur at regular though infrequent intervals. Often patients are hesitant to call with concerns that they feel are unimportant, yet can affect their recovery. Monitoring can reveal barriers to patient compliance with instructions, such as lack of understanding, language or cultural issues, personality issues, logistical barriers of transportation, lack of family support, or time barriers. Early adjustments to these issues can prevent crises later.

To obtain accurate, truthful information, the case manager must maintain a rapport with the patient, family, provider, and payer. Considerate and respectful interchanges are required. The case manager monitors care through verbal reports, phone calls, written reports, and progress notes, and compares information to determine areas that may need further exploration or clarification.

If discrepancies exist in the reports, the case manager explores them to clear up any confusion and obtain clear, accurate information. Many providers have been trained to document a patient’s progress only to meet reimbursement requirements and may omit problems so payment for services is not jeopardized. If the patient makes only negligible progress, the provider may exaggerate it. Or, the progress may be measurable clinically, but not result in functional improvement. The case manager gathers information from many sources to obtain the most accurate information.

Evaluation

Evaluation is carried out on completion of the plan, at designated intervals, and on an as-needed basis.¹ Frequently, evaluation is a continuous process in case management. Evaluation is a method to measure the quality and outcomes of products and services provided.

Evaluation provides an opportunity for the case manager to review whether the plan’s activities have produced the anticipated result and, if not, to explore why. Evaluation can influence decision-making about further plans and resource allocation and help to establish best practices.

The case manager continually evaluates the patient’s responses to treatments, approaches, and the provider. The case manager evaluates the effects of the treatment and effectiveness of the plan not only on physical recovery, but also on mental and emotional attitudes, including the effects on family or lifestyle. The case manager evaluates the appropriateness of the frequency and duration of treatments based on the patient’s circumstances and progress, and the actual outcome as compared to the expected outcome. A case manager who realizes that a patient’s progress is not as expected must determine why, and take steps to intervene.

Successful evaluation requires skill to know what to look for and to ask the right questions. Evaluation information can include clinical data, physical gain, functional improvement, patient satisfaction, and progress toward goals. The case manager needs to be familiar with the normal anticipated rate of progress to determine whether the service provided is of value.

What is learned through evaluation is then used to set up additional monitoring points, modify or alter the plan, or reassess the case. The case manager uses evaluation results to support the case management interventions, plan, and decisions. Evaluation can also be used to change an existing program or technique, design new programs or approaches, or conduct outcomes research to develop benchmarks and best practice guidelines.⁴

The case manager is accountable for the responsible allocation of resources and their appropriate use. The case manager seeks outcomes information to determine the cost/benefit ratio and value of specific programs and interventions. The case manager should incorporate outcomes information into his or her recommendations for services or referrals to outside programs so that patients are referred to the programs and services most suited to their needs. Outcomes information can also be used to improve systems internally.

In most settings, case managers use multiple components of the process simultaneously, especially in complex cases. The case management process is circular, with movement possible in both directions at various levels at the same time. For example, a patient who has undergone surgery to repair a hand injury and has progressed smoothly with hand therapy will be in the monitoring phase for physical rehabilitation, but may also be ready for a psychological assessment to identify any psychological or emotional barriers to return to work.

If unexpected changes occur during plan implementation, further assessment may be needed to explore how these will affect treatment and recovery. The processes of monitoring, evaluation, and assessment are used repeatedly to develop a dynamic case management plan that adjusts to meet the changing needs of the patient.

Chapter 3 - Areas of Knowledge 

To practice effectively and efficiently, the case manager must learn three areas of knowledge. The areas are basic case management concepts, including case management principles, process, relationships, strategies, and standards; how the healthcare delivery system and reimbursement works; and the specifics for the population or setting served by the case manager. This information is often learned on the job. Knowledge in these three areas provides a foundation from which case managers can perform the activities their role requires. This chapter will cover basic case management concepts and setting specifics. The healthcare delivery system will be covered in Chapter 4.

Case management concepts

Case management concepts form the foundation for case management practice. The concepts include the philosophy and goals of case management and are covered in Chapter 1. The case management process consists of several essential activities: assessment, planning, implementation, coordination, monitoring, and evaluation. These essential activities are covered in-depth in Chapter 2.

Case management is relationship-based. The case manager works directly with the patient; he or she contacts the patient, obtains consent for services, and develops mutual goals. In some settings, early identification of patients likely to need case management services is an important function of the case manager. Case managers may be asked to identify patients who would benefit most from their services. The case manager uses knowledge of case management outcomes to select those at high risk for complications or to identify barriers to recovery that respond well to case management.

Case managers also work with others; they are the liaison for patients, families, payers, vendors, community agencies, physicians, and other medical and non-medical providers. Case managers negotiate, collaborate, and communicate throughout the case management process. The strength and nature of their relationships strongly affects their effectiveness.

The case management approach is holistic. The case manager knows the medical, psychological, and behavioral aspects of illness and how they relate.

Case managers are patient advocates; they balance what patients want with what they need within the context of available resources. Case managers empower patients when they inform them of their options. Case management is goal-oriented and works to achieve the highest level of function and independence possible for the patient within the least restrictive environment.

Case managers are educators; they provide patients with the information they need about their condition and treatment — or help them find the information. Case managers can educate patients and families about the healthcare system and its processes. They can educate patients and families about their insurance benefits and how to access them. Case managers also educate their patients and other clinicians about their role.

Case management strategies are the basis for case management interventions that produce desired outcomes. These interventions include techniques to provide patient education, engage patients to increase their participation in care, and obtain their cooperation and agreement, all of which increase adherence and lead to positive health outcomes. Case managers use key skills that will be covered in-depth in Chapter 5 to carry out these interventions. They are critical thinking, communication, negotiation, and collaboration.

The case manager uses critical thinking to assess and evaluate progress continually, and problem solve when needed. Interventions that facilitate care coordination and communication are included in the case management strategy. Techniques that enhance communication, negotiation, and collaboration are also part of the case management plan. Conflict resolution techniques and strategies are needed when competing interests and goals are present. Case managers use communication, negotiation, and collaboration to implement plans and reach consensus.

Case managers must be familiar with the standards of practice developed by the Case Management Society of America.¹ They also should know the practice act and standards of their professional license as well as the policies and procedures of their employers.² Since case management is performed by many types of healthcare professionals, each case manager needs to know the practice act that governs his or her scope of practice.¹

Organizations have developed documentation requirements to standardize the content of their reports. Documentation of case management activities helps case managers perform efficiently and is a valuable communication tool for others who work on the case. Documenting the patient’s response to case management activities, the choices and options given, and the rationale for decisions will be useful if a dispute occurs. The case manager must understand documentation standards to track interventions as well as to meet legal, regulatory, and organizational requirements.³

Case managers must adhere to the reporting requirements for healthcare professionals as well as the regulations that protect patient information.³ Patient privacy standards require the case manager to protect the confidentiality of the patient information they receive and take reasonable precautions to safeguard it.^3,4 Mandatory reporting requires healthcare professionals to report elder and child abuse and neglect, threats of harm to others, and certain communicable diseases.³ Case managers need to know the regulatory agencies that govern their states and practice settings so they can adhere to the requirements.

Knowledge of roles and responsibilities will prevent case managers from putting themselves and their organizations at risk. Professional organizations are valuable resources to keep abreast of legislative and regulatory activities in the industry. Awareness of legislative changes will enable the case manager to practice confidently and efficiently.

Healthcare delivery system and reimbursement

The healthcare system and reimbursement mechanisms are increasingly complex. Today’s healthcare system requires that the case manager know payer processes and requirements to be effective. This will be covered in detail in Chapter 4.

Coordinate levels of care

Case managers work with patients at various stages of the care continuum, from wellness and prevention to end-of-life care. Often, the case manager’s role is to facilitate and coordinate care between levels and from one setting to another. This can include ambulatory care, inpatient or outpatient services, home health, rehabilitation, subacute, and transitional care. Skilled nursing, assisted living, and long-term care settings are also options. Case managers need to understand the various levels of care, how they are reimbursed, and what they entail. For example, physical therapy can be done in outpatient, inpatient, and home care settings.

The case manager works with various facilities and agencies to transfer patients from one level of care to another. It is necessary to know the requirements and the process to admit, transfer, and discharge patients to ensure their smooth transition from one level of care or provider to another. Information such as lab values, test results, medications, frequency and complexity of treatments, medical stability, and functional status commonly determine the level of care.

Knowledge of how the healthcare system works is also important for the case manager when making referrals. To know whom to call, how to make a referral, and the necessary information will expedite receipt of services.

The case manager sets up services for patients, taking into consideration standard treatments, the anticipated course and length of recovery, community norms, and basic safety. He or she assesses the options available for the type of care needed, obtains information about the feasibility, availability, safety, and accessibility of each option as well as the coverage or need for funding for each. The case manager sets up referrals with reputable providers who can best meet the needs of the patient, and ensures that pertinent information is transferred. The case manager follows up to be sure services are provided as arranged. The case manager may have to coordinate benefits if more than one source of funding is needed.

The case manager ensures the best use of resources, which means the best value and benefit for the cost. The case manager needs to know the plan limitations to ensure that benefits are not exhausted prematurely; otherwise, other funds will need to be secured to carry out the treatment plan. In some settings, critical pathways or other practice guidelines are used. These practice guidelines can be helpful as resources and tools; however, care and treatment decisions should always take into consideration the patient’s condition, circumstances, and needs. Factors such as patient preference, access to other needed services, medical appointments, and family finances should be considered. A patient who wants to return home but has no home support may be able to pay for private home assistance in lieu of care at a skilled nursing facility.

Case managers evaluate the pros and cons of various options and consider not only costs, but outcomes and personal factors, such as patient lifestyle and preferences, to ensure the plan is appropriate and will provide the intended outcome. The feasibility of each option will depend on the patient’s clinical condition, endurance, home support, and access to services.

The case manager monitors that services are still appropriate and helps transition the patient to the next phase when needed. The case manager continually communicates, coordinates, and facilitates as needed, and continually monitors and evaluates to ensure the plan remains appropriate. If needed, reassessments and modifications are made. If gaps in care are identified, the case manager arranges for other resources.

Ultimately, case managers must drive what is needed to obtain positive health outcomes; they prioritize and maximize whatever resources are available to be cost effective. The case manager can negotiate rates when needed, and compare costs and provide a cost benefit analysis when appropriate. When weighing cost benefits, the case manager must include both hard costs (actual dollars) and soft costs (factors that may not have an exact dollar measurement, but will affect the cost of the claim). Hard costs include hospital bills, physician fees, and medical supplies. Hard costs are easier to measure and can show clear savings as a result of discounted fees, elimination of duplication, reduction of inappropriate services, or delays in care.

Although soft costs are more difficult to measure, they are of equal if not more importance.⁷ Soft costs include the human and social consequences, such as lost wages, company productivity, future job marketability, future medical expenses, quality of life, and the avoidance of pain and suffering.

Case managers must be sensitive to both types of costs to promote and advocate for the most appropriate plan, further demonstrating the value of case management services. (See Table 1.) In some cases, the case manager can negotiate more benefits or coverage from the payer when he or she explains the rationale and plan.

Knowledge for the practice setting

The case manager who works with a specific disease or population develops expertise in that area. This includes not only the evidence-based treatment and community standards but the expected clinical course, common services, resources, and specialists available. A case manager who works with elderly patients develops expertise and skills with a geriatric population as well as knowledge of Medicare benefits, common diagnoses, and community resources for the elderly. Other specialty areas for case management include organ transplant, high-risk pregnancy, spinal cord, and brain injury. These high-cost diagnoses have been selected because of their successful outcomes with case management. Other diagnoses commonly chosen for case management include diabetes and congestive heart failure.

The case manager should know the scope of practice for various medical professionals, the pros and cons of treatment in different settings, and what best fits the patient’s situation and needs. Case managers in a mental health clinic may spend most of their time on community resources while disability case managers may focus on vocational concepts and strategies. In some settings, the case manager works with a range of diagnoses and is not expected to be a clinical expert but a generalist. In other settings, the case manager will develop expertise in a specific clinical area. The case manager should learn the common treatments, standards of care, and generally accepted practice guidelines for the population served. When case managers know the routine care, common medications, and common barriers, they can develop realistic plans and goals to coordinate care and services for their patients. If a case manager works with a common cultural group, he or she needs to know the cultural norms and beliefs for that group for maximum effectiveness.

Psychological factors during illness and injury can play a huge part in the patient’s physical recovery. Common feelings during illness and injury include sadness, grief, depression, frustration, anger, dependence, blame, and helplessness. Psychological factors determined to be a significant influence on a patient’s outcome must be included and addressed in the case management plan. Case managers need to be familiar with the normal stages of loss and grief, role and body image changes, and common coping mechanisms. Case managers should also be alert to behaviors associated with depression, chemical dependency, and psychological crisis, such as missed appointments, social isolation, and mood swings. Patients may be anxious about treatments, anticipated discomfort, future and long-term consequences, finances, family worries, relationships, role changes, and loss of identity. The case manager can help when he or she keeps the patient informed and acts as a liaison or facilitator to resolve issues as they arise.

Support systems are often critical in the successful treatment and recovery. Many hospital systems, clinics, and health plans offer educational services to the public. Other resources include local and national support groups, pools, gyms, and recreational programs for the public as well as the disabled. Family, friends, students, religious communities, and volunteer agencies should be mobilized whenever possible. The case manager must be familiar with resources which provide for the psychological and social needs of the patient. Social workers and social service agencies can be an invaluable resource. The case manager should be familiar with the community resources and services typically used or needed by the patient population. Patients may need help with transportation, housing, food, finances, and companionship. The case manager helps access community resources and includes these resources in the case management plan. The case manager should be aware of both formal and informal support systems, assess the patient’s needs and available resources, and provide referrals and information as needed.

The case manager should understand human behavior, behavior modification, and established techniques and strategies to work with a specific population. Information about past or recent psychiatric illness and treatment or substance abuse should be in the treatment plan. It may be appropriate to build psychological counseling or support into the treatment plan and select a vendor that will provide that support. The case manager can closely monitor and evaluate for potential problems, communicate any issues to the physician, and arrange for added support if needed.

In addition to community resources for care, the case manager needs to be familiar with the legal and ethical practices in his or her community. The case manager needs to know the standard of practice in the community to minimize potential liability and malpractice claims. Case managers should consult with their peers and act proactively to develop a network to keep up-to-date on controversial treatments and practices in their settings and to be aware of developing trends or areas of increased liability. For example, case managers who work for an insurance company should know the time frames for authorization to ensure that they are in compliance with any regulations that apply to their practice setting. Areas of increased liability in the insurance setting include wrongful denials, acting in bad faith, breach of contract, and credentialing negligence.^4,5 Ethical issues are a common dilemma for case managers. Debates about end-of-life care and how to balance competing interests occur in every setting.

In some settings, such as workers’ compensation, a return to productive activity is essential to positive outcomes.⁸ Job loss has an enormous effect on healing, recovery, and quality of life. Vocational goals may strongly influence treatment decisions and will affect recovery. Case managers ensure that functional recovery for activities at work and home remain a key goal in the treatment plan.

In some settings, case managers are involved in long-term planning and vocational rehabilitation to return patients to work. They should understand return-to-work principles and strategies. These case managers may be involved in job analysis, ergonomics, life-care planning, the projection of future maintenance care, and costs for those with a catastrophic injury. Case managers in these settings need to know workers’ compensation and disability laws and regulations. 

Case managers who work in the disability setting should have access to resources that cover the legal rights of the disabled and job modification strategies. Other resources include vocational experts, disability consultants, and assistive device vendors. The case manager may initiate and coordinate services, if appropriate, to ensure the necessary information is communicated and to explain the processes to the patient and family. The case manager arranges for assistive devices, structural modifications, adaptive equipment, resources for those with disabilities, and job retraining, if needed. Knowledge of community resources and services, the referral process, and laws that affect people with disabilities helps case managers reintegrate patients into their normal work, family, and community lives.

The case manager is part of a team. The team may consist of other healthcare professionals, administrative staff, or anyone who is involved in the patient’s care. Since the primary function of the case manager is to facilitate and coordinate care, the case manager depends on all the members of the team, and the team relies on the case manager to carry out his or her role effectively and efficiently. The case manager uses communication skills and knowledge of the setting to build credibility with others.

All case managers need to know case management concepts, principles, and strategies and to understand the healthcare delivery system and reimbursement relative to their populations and settings. Case managers develop increasing knowledge and expertise specific to their settings and populations over time.

Chapter 4 - Navigating the System 

The case manager facilitates and coordinates care for patients. To do this, the case manager must understand how healthcare delivery systems work. This chapter discusses delivery systems, methods of reimbursement, and common benefit programs. Managed care strategies and how they affect the role of the case manager will also be covered.

Delivery, reimbursement

Several types of delivery systems and reimbursement systems have emerged as hospitals, physicians, insurance plans, and others try to design systems to provide cost-effective health care. Private insurance, paid predominantly by employers, continues to be the largest payer of healthcare expenditures in the United States, followed by Medicare and Medicaid, known as Medi-Cal in California. (See figure, next page.) Each of these payer systems can use any of the delivery systems and methods of reimbursement presented to provide services. (Note: The term member is used interchangeably with patient when explaining insurance benefits.)

Fee-for-service, indemnity

Fee-for-service/indemnity insurance plans pay healthcare providers based on each service provided. This is known as fee-for-service reimbursement.¹ Although indemnity plans were used almost exclusively in the past, their popularity has declined in recent years because of rapidly rising premiums. Because these plans pay up to 100% of the billed or allowed amount, increases are simply passed on as increased premiums. Fee-for-service reimbursement is believed to encourage providers to provide unnecessary medical care since providers are paid according to the number of procedures performed.²

Case rate, per diem, discount

With the case rate form of payment, the provider is reimbursed based on the type of case or patient diagnosis, as opposed to the amount of services rendered or length of stay. This is commonly done by Medicare for hospital stays.¹ Medicare pays the hospital a set fee based on the patient’s diagnosis codes or diagnosis related group (DRG). Medicare also uses this form of payment, which is known as prospective payment system (PPS), in home health, acute rehab facilities, and skilled nursing facilities (SNFs).

The per diem form of payment is common for facilities and institutions, as well as pharmaceutical companies. The healthcare provider is paid a set fee per day from the first day of care to the last day of care. The rate covers all care regardless of the amount of services provided.¹ For example, a home infusion company with a $25 daily per diem rate would be paid $525 ($25 x 21 days) for a three-week course of IV antibiotics. This would include the medication, supplies, nursing visits, and teaching. The per diem rate is a common method of reimbursement for home infusion, hospice care, and SNFs.

Discounted rates are often given in exchange for volume, prompt payment, or other negotiated arrangements. This is simply a percentage off the regular charges.

Capitation, carve outs, shared risk

Capitation is another method of reimbursement used increasingly in health care to control costs. This method of payment for services shifts the financial risk to the provider of care.^2,3 In the capitation method of payment, a predetermined amount is paid each month to a provider in exchange for an agreed-upon service to a select group. The amount paid is fixed, calculated by the number of members who belong to the group during the defined time period.¹

For example, a physician contracted with XYZ Health Plan for $1.50 per member per month (PMPM) will receive $1,500 each month (1,000 members) in exchange for primary care services to any XYZ members who need care that month. The provider receives $1,500 monthly regardless of the services provided.

The capitation method of reimbursement encourages efficiency and discourages unnecessary activities; however, it can result in quality problems and frustration if not understood or well managed. Some believe capitation provides an incentive to withhold care;³ this is an area for further study.

Capitation rates are usually set by the insurer and are based on average data and statistics per thousand people. Many factors can be used to determine these rates, such as age, sex, geographical area, and past utilization. Groups whose characteristics are significantly different from those on which the rates are set may not follow the same utilization rates. Likewise, groups with inadequate numbers (under 1,000 members) may vary, as statistics are based on volume averages.

A carve out is a service that is specifically excluded from a provider contract. Providers are not responsible for services that are carved out of their contract.¹ Carve outs are typically arranged for unusual specialty services, such as organ transplants or psychiatric care, that the contracted provider is not able to provide. The payer can then contract with another provider for those services alone.

Risk sharing is a process in which an HMO and contracted provider each accept partial responsibility for the financial risk and rewards involved in the care of their shared members. The terms and amounts are then delineated by their contract.¹

HMOs

The health maintenance organization is one type of managed care organization. An HMO is responsible for both the financial risk and delivery of healthcare services. To control costs, HMOs control and monitor provider behavior and restrict member choice. A primary care physician may be a gatekeeper to manage referrals to specialists and other services. Most HMOs hire providers as employees or contract with providers to provide services at a capitated rate, which allows them to control costs.² Both Medicare and Medicaid offer HMO plans.

The HMO concept has shifted the focus from acute services to preventive care. Providers are no longer reimbursed based on the numbers of procedures performed; instead, under capitation, providers have an incentive to keep members healthy so they require fewer services. Case managers have the opportunity to manage chronic diseases as well as to provide patient education and promote preventive care.

Many HMOs provide prevention, screening, well care, and immunizations at little or no cost to members. Annual physicals, Pap smears and screening tests, mammograms, prenatal care, and medications are frequently covered at 100% to encourage members to obtain preventive care. When HMOs keep members healthy and provide early intervention, costly treatment and care often can be avoided. It is much easier and cheaper to treat hypertension than to wait for a stroke. Likewise, diabetics who cannot afford blood testing equipment will most likely be noncompliant with a diabetic regimen; this will ultimately result in much higher costs of diabetes-related complications and the potential for many other serious health problems.

Although HMOs are popular because of low premiums, consumers also want choices. Many HMOs expand their product lines to provide options to members.

PPOs

A managed care organization that has gained popularity is the preferred provider organization (PPO). A PPO encourages members to obtain care from a list of preferred providers,¹ those who have signed a contract to provide services at a predetermined rate, usually a discounted rate, in exchange for volume. They agree to provide services according to the fee schedule given and agree to abide by terms for how the provider and insurance plan will do business. PPO plans give members the option to obtain services from providers not on the list; however, services are paid at a lower percentage, which leaves the member with a larger out-of-pocket cost on deductibles and co-payments. This strategy has encouraged members to use contracted providers.^2,3

Point-of-service plans

A similar type of plan, the point-of-service (POS) plan allows members to receive care from contracted providers or from providers outside of the plan. Members are encouraged to use contracted providers because of the fuller coverage.¹

Other plan combinations

Physicians and group practices have banded together to form independent practice associations, or IPAs.¹ An IPA negotiates on behalf of its physician members to get large contracts from insurers in exchange for assuming responsibility for the care of these members. The IPA can share resources such as administrative support, marketing, or space to achieve increased efficiency and bargaining power through volume and can offer a complete range of services to insurers.

Hospitals and physician groups also team up to provide a package to insurers. PHOs (physician-hospital organizations) and PHAs (physician-hospital alliances) are partnerships of physicians and hospitals who develop a formal relationship to negotiate a contract for service directly with insurers or employers through employee unions and business coalitions.¹

Many HMOs incorporate successful elements of several plans to create new products and combinations. Many new products and changes are expected as the industry builds on experience and obtains input from consumers.

Evaluate delivery systems

Case managers are encouraged to examine the key delivery system issues raised in the questions below. The answers will assist the case manager to plan for realistic time frames for processes and provider behaviors, and understand where to go to resolve conflicts.

What are the methods of payment to providers — is it a fee schedule, percentage discount, or capitated? What is the financial relationship between the providers and the plan? How are providers paid? Are the physicians salaried or contracted? Who has the power to make decisions? Is there an insurance board, panel, or medical director who is the ultimate decision maker, or is it up to the treating physician? Where is the financial risk — do the physicians share in the profit or loss, and are there financial incentives or bonuses? If capitated, what is done with the money not used?

The language of insurance

In many organizations, specially designated staff handles benefits — who is eligible, what is covered, and what is not. The case manager may not be directly involved with these areas; however, knowledge of the process and what is involved is helpful to understand how things are done and where to intervene when needed. In some settings, it is the responsibility of the case manager to explain benefits or coverage to patients and help them make decisions about how they want to use their benefits.

Eligibility, benefits, limitations

For a patient to receive benefits, certain criteria must first be met. The first criterion is eligibility. The patient must be eligible for the plan. For government plans such as Medicare and Medicaid, federal and state mandates determine eligibility.³ For private insurance, the policy determines eligibility. The patient must be confirmed as covered under the plan during the time services are rendered. Patients may mistakenly believe they have coverage when in fact they may not. Lapses in coverage can occur with job changes, marital changes, and missed premium payments. Eligibility must be confirmed before services are initiated.

Once eligibility has been established, the next question is whether the plan has the service needed as a covered benefit. Although government-sponsored plans have standard benefits, group health plan benefits can vary widely. 

If the service is a covered benefit, check the conditions of the policy and exclusions for predisposing or overriding factors that would affect coverage, including preexisting condition clauses. Some plans have exclusions and restrictions about travel and care out of the area. Some services are covered only if certain conditions are met, such as SNF coverage only after a qualifying hospitalization. Pay attention to lifetime maximums, annual limits for certain services, and maximum allowable charges. Annual limits can be for a calendar year (January to December) or for any consecutive 12 months. Benefits are normally outlined in the member’s handbook, and most plans have a toll-free number for this information.

Deductibles, co-pays

The deductible is the amount a member must pay out-of-pocket each year before the insurance payments begin.¹ Plans with a high deductible ($500-$1,000) have lower premiums than those with lower deductibles ($100-$250). A deductible can be a barrier to early treatment and preventive services such as annual checkups. For this reason, HMOs typically have a zero or low deductible. Case managers may need to explain these processes to patients or, in some cases, locate other financial resources if patients cannot pay the deductible.

Co-payments are a patient’s share of the cost for each designated service.1 For example, many HMOs provide all medications but may require a small ($1-$15) co-pay from the patient per prescription. Medicare requires a co-pay for many covered services.⁴ Although co-payments can be barriers to care, studies show co-pays reduce the demand and prevent overutilization of services.² PPOs provide a strong incentive for members to obtain care through preferred providers by increasing the out-of-pocket expense from 10-20% for preferred providers to 30-50% for non-preferred providers. If services are through a non-PPO or out-of-network provider, the case manager must be sure patients understand their out-of-pocket costs. The case manager also coordinates benefits when multiple coverages are involved.

Common benefit programs

Medicare and Medicaid are two common benefit programs. The Medicare program is federally funded and regulated. Medicare provides health care for people 65 years of age and older. Medicare also provides health care for people who have been disabled for at least two years and for those with permanent kidney failure. In general, Medicare is a free benefit for citizens or permanent residents of the United States who meet the eligibility requirements; however, sometimes a person can pay a monthly premium to obtain benefits.⁵ In recent years, the program has undergone some significant changes, and minor changes can occur from year to year. The most recent information is available at www.Medicare.gov.

Medicare Part A is for hospital or institutional care and covers inpatient hospitalization services, skilled nursing facility care, home health, and hospice care. Medicare Part B is for medical or non-institutional services, such as physician visits, outpatient services, supplies, and equipment.⁵ Medicare benefits are the same across all states. Patients with standard or traditional Medicare have no limitations on whom they go to for care, and fees for many services are paid similarly to fee-for-service insurances. For some services, such as inpatient hospitalization, home health, and acute rehabilitation, Medicare pays on a case rate basis. (Medicare also has HMO plans. Advantages of Medicare HMOs include lower deductibles and co-payments, more coverage, and no claim forms. One disadvantage is a limited choice of providers.) Medicare Part D covers prescription medication.

The Medicaid program was designed for the low income and needy — the qualifications are based on income and disability status.⁶ (In California, the program is known as Medi-Cal.) Medicaid benefits and eligibility can vary from state to state. Recipients include children and the blind, aged, and disabled who fall within the income limits set by the state and federal government. (As with Medicare, Medicaid has HMO programs; in some states certain populations are required to enroll in these HMOs.)

Other federal benefit programs include Tricare (previously known as CHAMPUS), which covers active and retired military personnel and their dependents,⁵ and Longshoremens and Harbor Workers Compensation for Merchant Marines.

There are other types of insurance that cover medical expenses such as auto, long-term care, travel, and workers’ compensation. These function similarly to indemnity insurance plans. Each has its copayments and deductibles, and rules about coverage. Case managers will develop expertise as they work with the programs most common in their populations and settings.

Preauthorization, bill review

Case managers need to understand how the authorization and referral processes work within the payer system to enable them to access and route requests smoothly and efficiently. The case manager works with claims personnel, utilization review staff, providers, and anyone else needed to channel the necessary information to the appropriate people in the payer system.

Utilization review, bill review, and prior authorization are commonly used to prevent excessive or unnecessary charges. Utilization review evaluates and screens requested services for appropriate frequency, duration, and criteria for continuation of services. In general, it uses criteria that establish the average level of care and length of stay for patients based on age and diagnosis. Utilization review is often done initially by nurses or claims personnel and then passed on to a physician, medical advisory board, or utilization review committee for review and a final determination, if needed.

Bill review is a service that audits bills to check for appropriate coding, duplication, excessive charges, and billing errors. Charges must match services rendered as well as be supported by documentation in the medical record. Billed charges are also compared to usual and customary charges for similar services in the same geographic area.

Most health plans have a review system for prior approval of services to ensure they meet medical necessity criteria. Criteria include clinical data; intensity, frequency, and duration of services; treatment prognosis; medication and routes of administration; and medical stability. The process is set up based on the needs and preferences of the insurer or health plan. The case manager frequently facilitates the authorization process.

The case manager should be familiar with the treatments that require preauthorization and be prepared to give the information required for the decision to be made. The insurer may need medical or diagnostic information, cost, anticipated outcome, and prognosis. The case manager will find out to whom or where the information needs to go, in what form, and when to expect a decision. For referral authorization, the case manager should be prepared to provide information about a provider’s credentials, area of expertise, whether the provider is in the network, and any other information the claims personnel may need to process the request.

Importance of case managers

Since case managers secure and coordinate services and care for patients, they need to know how to maneuver skillfully through the provider and payer systems. The case manager facilitates reimbursement and can prevent disputes, denials, and delays in payment and authorization.⁵ When case managers know benefits terminology and how the process works, it helps them communicate with claims staff. Case managers can explain when unusual situations call for plans out of the normal range or services not in the standard benefit package.

For patient referrals, the case manager must check for preferred provider status and include this information in the provider options.

To avoid conflicts, case managers must be aware of existing contracts when they negotiate and set up services. The case manager explains the options to the patient, including information about co-payments and deductibles, if needed.

In fee-for-service arrangements, the case manager watches for overutilization; in case rate and capitation, for underutilization. With discounted fees, the case manager must confirm that an agency can provide services at the designated rate; sometimes discounts are accompanied by a reduction in quality or service area, a delay in initiation of service, substandard equipment, or omission of supplies normally included. Case managers can work efficiently and effectively when they are aware of the advantages and disadvantages of various delivery systems and reimbursement methods.

Chapter 5 -  Key Skills

Each case manager brings a unique background and blend of professional knowledge and experiences to his or her work. The success of the case manager will depend on how the knowledge and skills are used. The effective case manager is strong in critical thinking, communication, negotiation, collaboration, and advocacy.

Critical thinking

Critical thinking is a logical, systematic method to organize and analyze information.¹ The ability to process information in a way that shows focused, purposeful thinking based on facts and known human strategies is an indispensable skill. Case managers must be able to think critically to be effective.

Critical thinking requires that information is obtained and viewed in a way that reduces outside bias and influences. When a systematic method to gather and review information is developed, the case manager avoids quick conclusions and opinions based on incorrect assumptions, or inaccurate or incomplete information. Critical thinking is important in gathering information, prioritizing, analyzing and synthesizing information, problem solving, making decisions, and evaluating. See Tables 1 and 2.

The case manager often sorts through and synthesizes large amounts of information to determine what is pertinent, including information from patient interviews, observation, and reports. Medical records include hospital records, diagnostic reports, and progress notes from therapists, physicians, and healthcare specialists. The case manager identifies the missing information and what needs a more careful review. He or she organizes the information in a useful and logical way, and identifies existing and potential issues. Because information is continually added, the case manager constantly sorts and processes new data as appropriate to update the file.

It is a challenge to evaluate the credibility and reliability of the information. The case manager cannot assume anything — just because a test was ordered and scheduled doesn’t mean it was done. Medications prescribed for a patient may never have been taken. When conflicting information is found, the case manager must delve further to determine what is accurate.

Once problems have been identified, the case manager sets priorities; this drives the case management goals and plan. Not only does prioritizing help to develop the case management plan, it keeps others involved with the patient focused and clear. Often, patients have multiple needs; set priorities prevent chaos and confusion.

The case management plan must take into account any pressing needs and concerns of the patient, as well as address serious, life-threatening, or potentially damaging problems. The case manager considers the likelihood of occurrence as well as the affect of the complication if it occurs. If the potential for serious complication is remote, the case manager decides the amount of emphasis to give in that area.

After priorities are set, the case manager looks at the problem areas, identifies and explores options — compares the outcomes, advantages, and disadvantages of each — and, after discussion with the patient, chooses a viable solution. Extensive work and interaction with the patient, family, and others may be necessary. Decisions must take into account recent literature and outcomes, treatment standards, the past experience of the case manager and others, and the patient’s needs. A trial period to test a new treatment or approach may be considered before a final commitment is made.

Critical evaluation is a logical process to evaluate the outcomes, results, or effectiveness of a treatment, program, or strategy.¹ First, the case manager retrieves and organizes the appropriate information which depends on what is evaluated. For example, if the evaluation is for the effectiveness of a rehabilitation facility, the functional abilities of patients at discharge are as important as the average length of stay. The case manager identifies any inaccuracies and inconsistencies in outcome data and analyzes the information to reach a conclusion.

Throughout the critical thinking process, the case manager continually probes, explores, and revalidates the assumptions on which the case management plan has been built. Sometimes, during the course of care, circumstances change, which changes the premises of the plan. Often, the patient is unaware of the influence of these changes and may forget or not disclose this information. The case manager actively checks and rechecks information to ensure that plan changes are made when needed and to prevent complications when able. The case manager must recognize when things have changed and alter the plan accordingly. The case manager continuously evaluates alternatives so that a backup plan is ready.

Communication

The next essential skill used by the case manager is communication. The case manager obtains and delivers information to others. The case manager must have skills to elicit accurate information and facilitate truthful disclosure. This requires skills in verbal and nonverbal communication, and in telephone and face-to-face interviews.