Case managers as part of the interprofessional team
In any setting, the professional case manager is the individual who is the primary care coordinator. He or she is aware of the patient-centric plan and the necessity of keeping to the plan. The case manager is the chief communicator to all the other team members. This responsibility is clearly delineated in the Case Management Society of America Standard, Facilitation, Coordination, and Collaboration. This standard states, “the professional case manager should facilitate coordination, communication, and collaboration with the client, client’s family or family caregiver, involved members of the interprofessional health care team and other stakeholders, in order to achieve target goals and maximize positive client care outcomes.”
In order to achieve the case management outcomes, the case manager must engage in the case management process. This is a series of steps similar to the nursing process or a process improvement exercise, but the case management process involves the interdisciplinary team and most importantly the patient and his or her family or caregiver. The case management plan must involve the patient and/or his or her caregiver as active participants.
The patient or client assessment is a case management standard that involves an extensive assessment that takes into consideration the patient’s cultural, linguistic, and health literacy. It is inclusive of the patient’s medical and behavioral needs.
Identifying the care needs of the patient is also a case management standard. The case manager identifies needs, barriers, and gaps in care. The standard of planning is evidenced by a documented plan of care written by the patient and family in collaboration with the interdisciplinary team. The case manager monitors the plan evolution and determines whether the goals are met. If the plan is not working, the case manager must reevaluate and adjust it. The case management plan is continuous in nature, and success is realized through both short- and long-term goal achievement.
The case manager is most often a certified case manager. He or she does not treat patients; rather, he or she assists patients in receiving necessary care, measured by outcome metrics. The case manager assists the patient to stabilize medical, behavioral, and cognitive health through his or her understanding of disease management and the social barriers that may deter the achievement of healthcare goals.
Editor's note: This is an excerpt from HCPro's Case Management Guide to Population Health: Management Across the Continuum of Care. Click here for more information.