Introduction to the Case Management Body of Knowledge PDF

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I nt r oduct i ont ot heCaseManagement BodyofKnowl edge Thecasemanagementk nowl edgef r amewor kc ons i st sofwhatc as emanager sneedt o k now( k nowl edge,s k i l l s,andcompet enc i es )t oeffect i v el yc ar ef orc l i ent sandt hei r s uppor ts y st ems .I ti nc l udest womai nel ement s : 1.Ani nephaseCas eManagementPr oces s 2.Si xes s ent i al k nowl edgedomai ns( pr evi ousl ys ev endomai nst hathav ebeen updat edbas edonfindi ngsoft hecas emanager ’ sr ol eandf unct i ons t udyCCMC r ec ent l yc onduc t ed) Thes eel ement sar eappl i c abl ei nanyc ar eorpr ac t i c es et t i ngandf ort hev ar i ous heal t hc ar epr of ess i onal swhoas s umet hecasemanager ’ sr ol eand/ ort hos edi r ec t l yor i ndi r ect l yi nv ol vedi nt hefi el d.

Defini t i onofCaseManagement Ther ei snoones t andar di z edornat i onal l yr ecogni z edorev enwi del yacc ept eddefini t i on ofc as emanagement .AnI nt er nets ear c hf ort hedefini t i onoft het er m casemanagement wi l l r es ul ti nt hous andsofr ef er enc es .Suc hr es ul t sar ec onf us i ngf orcas emanager sand ot her swhoar ei nt er es t edi nc as emanagementpr act i c e.Youmaybeunabl et odi s cer n whi c hdefi ni t i oni smostc r edi bl eorr el ev ant . Des pi t et hel ar ges ear c hout c ome,ex per t swoul dagr eet hatt her ear enomor et han20 orsodefini t i onsofc as emanagementconsi der edappr opr i at e.Thes edefi ni t i onsar e av ai l abl ei npeer r ev i ewedpr of es s i onal c as emanagementl i t er at ur eoronWebs i t esand i not herf or mal doc ument sofc as emanagement( orc as emanagement r el at ed) or gani z at i ons ,s oc i et i es ,andgov er nmentornongov er nmentagenc i es .TheCas e ManagementKnowl edgeFr amewor k

Vi ewl ar geri mage Sot haty oudonotgetc onf us edasy our eadmat er i al si nt heCommi s s i onf orCas e ManagerCer t i fi c at i on’ s( CCMC)CMBOK®,t heex per tc ont r i but or swhodev el opedt he c as emanagementknowl edgef r amewor ki n2009deci dedt ous et heCommi s s i on’ s defini t i onofc as emanagementav ai l abl eatt hatt i met ogui det hei rwor k .( Not et hatt he defini t i onbel owhass i nc ebeenupdat edt or eflec tc ur r entappr opr i at ei nf or mat i on pr omul gat edbyCCMC. ) “ Cas emanagementi sapr of es s i onal andcol l abor at i v epr ocess t hatas s es s es ,pl ans ,i mpl ement s ,c oor di nat es ,moni t or s ,andev al uat est he opt i onsands er v i cesr equi r edt omeetani ndi v i dual ’ sheal t hneeds.I tuses c ommuni c at i onandav ai l abl er es our c est opr omot eheal t h,qual i t y ,andc os t effec t i v eout c omesi ns uppor toft he‘ Tr i pl eAi m, ’ ofi mpr ov i ngt heex per i ence ofc ar e,i mpr ov i ngt heheal t hofpopul at i ons ,andr educi ngperc api t ac os t sof heal t hc ar e. ”( CCMC,2015,p.4)

CaseManagementPhi l osophyandGui di ng Pr i nci pl es Cas emanagementi sas pec i al t ypr ac t i c ewi t hi nt heheal t handhumans er v i ces pr of es s i on.Ev er y onedi r ect l yori ndi r ect l yi nv ol v edi nheal t hcar ebenefi t swhen heal t hc ar epr of ess i onal sandespec i al l yc as emanager sappr opr i at el ymanage, effic i ent l ypr ov i de,andeffec t i v el yex ec ut eac l i ent ’ scar e.Theunder l y i nggui di ng pr i nc i pl esofc as emanagements er v i cesandpr ac t i cesoft heCMBOKf ol l ow: 

Cas emanagementi snotapr of es s i onunt oi t sel f .Rat her ,i ti sac r os s di s c i pl i nar y andi nt er dependents pec i al t ypr act i ce.

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Cas emanagementi sameansf ori mpr ov i ngc l i ent s ’heal t handpr omot i ng wel l nes sandaut onomyt hr oughadv ocac y ,c ommuni c at i on,educat i on, i dent i ficat i onofser v i c er es our c es ,andf aci l i t at i onofs er v i c e. Cas emanagementi sgui dedbyt heet hi c al pr i nc i pl esofaut onomy ,beneficence, nonmal eficenc e,v er ac i t y ,equi t y ,andj us t i c e.

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Cas emanager sc omef r om di ffer entback gr oundswi t hi nheal t handhuman

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ser v i cespr of es s i ons ,i nc l udi ngnur si ng,medi c i ne,soci al wor k ,r ehabi l i t at i on couns el i ng,wor ker s ’ compens at i on,andment alandbehav i or al heal t h. Thepr i mar yf unct i onofc as emanager si st oadv ocat ef orc l i ent s / s uppor t s y s t ems .Casemanager sunder s t andt hei mpor t anceofac hi ev i ngqual i t y out comesf ort hei rc l i ent sandc ommi tt ot heappr opr i at eus eofr es our cesand

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empower mentofc l i ent si namannert hati ssuppor t i v eandobj ec t i v e. Cas emanager s ’ fir s tdut yi st ot hei rc l i ent s–coor di nat i ngcar et hati ss af e,t i mel y , effec t i v e,effic i ent ,equi t abl e,andc l i ent c ent er ed. Cas emanagements er v i cesar eoffer edacc or di ngt ot hec l i ent s ’benefi t sas st i pul at edi nt hei rheal t hi ns ur ancepl ans ,wher eappl i c abl e. TheCas eManagementPr oc es si sc ent er edonc l i ent s / s uppor ts y st ems .I ti s whol i s t i ci ni t shandl i ngofc l i ent s ’ s i t uat i ons( e. g. ,addr es s i ngmedi c al ,phy s i c al , f unct i onal ,emot i onal ,financ i al ,ps y c hos oc i al ,behav i or al ,s pi r i t ual ,andot her needs ) ,aswel l ast hos eoft hei rs uppor ts ys t ems .

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TheCas eManagementPr oc es si sadapt i v et ocasemanager s ’ pr ac t i c es et t i ngs

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andt hes et t i ngswher ec l i ent sr ecei v eheal t handhumans er v i c es . Cas emanager sappr oac ht hepr ov i s i onofc as emanagedheal t handhuman ser v i cesi nac ol l abor at i vemanner .Pr of es s i onal sf r om wi t hi norac r oss

heal t hc ar eor gani z at i ons( e. g. ,pr ov i der ,empl oy er ,pay or ,andc ommuni t y agenc i es)ands et t i ngscol l abor at ec l os el yf ort hebenefitofc l i ent s / s uppor t s y s t ems .  

Thegoal sofcas emanagementar efi r s tandf or emos tf ocusedoni mpr ov i ngt he cl i ent ’ sc l i ni cal ,f unct i onal ,emot i onal ,andps y c hos oc i al s t at us . Theheal t hc ar eor gani z at i onsf orwhi chc as emanager swor kmayal s obenefi t f r om c as emanagements er v i ces .Theymayr eal i z el ower edheal t hcl ai mc os t s( i f pay or bas ed) ,s hor t erl engt hsofs t ay( i fac ut ec ar ebas ed) ,orear l yr et ur nt owor k andr educedabs ent eei s m( i fempl oy er bas ed) .

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Al l st ak ehol der sbenefitwhencl i ent sr eac ht hei ropt i mum l ev el ofwel l nes s ,sel f car emanagement ,andf unc t i onal capabi l i t y .Thes est ak ehol der si nc l udet he cl i ent st hems el v es ,t hei rs uppor ts y s t ems ,andt heheal t hc ar edel i v er ys y s t ems , i nc l udi ngt hepr ov i der sofcar e,t heempl oy er s ,andt hev ar i ouspay ors our c es .

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Cas emanagementhel psc l i ent sachi ev ewel l nessandaut onomyt hr ough adv oc ac y ,c ompr ehens i v eas s ess ment ,pl anni ng,c ommuni c at i on,heal t h educat i onandengagement ,r es our c emanagement ,s er vi cef ac i l i t at i on,andus e ofev i denc ebas edgui del i nesors t andar ds.

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Bas edont hec ul t ur al bel i ef s ,v al ues ,andneedsofcl i ent s / s uppor ts y s t ems ,and i nc ol l abor at i onwi t hal l s er v i c epr ov i der s( bot hheal t hcar epr of es s i onal sand par apr of es s i onal s ) ,c as emanager sl i nkc l i ent s / s uppor ts y s t emswi t happr opr i at e pr ov i der sofc ar eandr es our cest hr oughoutt hec ont i nuum ofheal t handhuman ser v i cesandac r os sv ar i ouscar es et t i ngs .Theydos owhi l eens ur i ngt hatt he car epr ov i dedi ss af e,effec t i v e,cl i ent c ent er ed,t i mel y ,effic i ent ,andequi t abl e. Thi sappr oac hac hi ev esopt i mum v al ueanddes i r abl eout c omesf oral l st ak ehol der s .

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Cas emanagements er v i cesar eopt i mi z edwhenoffer edi nac l i mat et hatal l ows di r ect ,open,andhones tcommuni c at i onandc ol l abor at i onamongt hec as e manager ,t hec l i ent / s uppor ts y s t em,t hepay or ,t hepr i mar yc ar epr ov i der( PCP) , t hes pec i al t ycar epr ov i der( SCP) ,andal l ot herser v i c edel i v er ypr of es s i onal sand par apr of es s i onal s .

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Cas emanager senhanc et hecas emanagements er v i c esandt hei ras soc i at ed out comesbymai nt ai ni ngc l i ent s ’ pr i v ac y ,confi dent i al i t y ,heal t h,ands af et y t hr oughadv ocac yandadher encet oet hi c al ,l egal ,acc r edi t at i on,c er t i fi cat i on,and r egul at or ys t andar dsandgui del i nes ,asappr opr i at et ot hepr ac t i ces et t i ng.

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Cas emanager smustpos s es st heeduc at i on,s ki l l s ,k nowl edge,compet enc i es , andex per i encesneededt oeffec t i v el yr enderappr opr i at e,s af e,andqual i t y ser v i cest ot hei rc l i ent s/ s uppor ts y s t ems . Cas emanager smustdemons t r at eas ens eofc ommi t mentandobl i gat i ont o mai nt ai nc ur r entk nowl edge,s ki l l s ,andc ompet enc i es .Theyal s omus t di ss emi nat et hei rpr ac t i c ei nnov at i onsandfi ndi ngsf r om r es ear c hac t i vi t i est ot he casemanagementc ommuni t yf ort hebenefitofadv anc i ngt hefi el dofc as e management .

Pr i nci palTer ms Manyt er msi nt heCMBOKhav emul t i pl emeani ngs ,andy oumaybeunc l earabout whi c hmeani ngt oappl y .Youmi ghtal s onoti nt er pr ett het er msi nt hewayt heknowl edge dev el oper s–whoar ec as emanagementex per t s–t houghtoft hem. T ogett hemos toutoft hek nowl edget heseex per t shav es har edi nt heCMBOK,t ak e t het i met or evi ewt hef ol l owi ngt er ms .Not et hatt hel i t er at ur emaydes c r i bet hes et er ms s omewhatdi ffer ent l y ;t hedes c r i pt i onss har edher ei nc l ar i f yt hei rus et hr oughoutt he CMBOK.

Pr i nci palTer msUsedi nt heCMBOK Term

Description

Client

The recipient of case management as well as health and human services. “This individ patient, beneficiary, injured worker, claimant, enrollee, member, college student, resid care consumer of any age group. In addition, [use of] the term client may also infer th the client’s support [system]” (CMSA, 2016, p. 32). NOTE: In the CMBOK, the term client is sometimes intended to include the clie system.

Client's support system

The person or persons identified by each individual client to be directly or indirectly i client’s care. It “may include biological relatives [family members], a spouse, a partne neighbors, colleagues, a health care proxy, or any individual who supports the client [ volunteers, and clergy or spiritual advisors]” (CMSA, 2016, p. 32).

Term

Description

Caregiver

The person responsible for caring for a client in the home setting and can be a family friend, volunteer, or an assigned healthcare professional.

Case manager

The health and human services professional responsible for coordinating the overall c to an individual client or a group of clients, based on the client’s health or human serv needs, and interests.

Case management program

(Also referred to as case management department.) An organized approach to the provision of case management services to clients and th systems. The program is usually described in terms of:

Case Management Process

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Vision, mission, purpose, goals, strategic objectives, and target outcomes Number and type of staff, including roles, responsibilities, and expectations of

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A specific model or conceptual framework that delineates the key case manag functions within the program or department

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Reporting structure within the organization How the program or department connect with or relate to other programs or d within the healthcare organization

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The process and metrics applied in the evaluation or the program or departmen contribution to the healthcare organization, especially its bottom line

The process through which case managers provide health and human services to clien systems. The process consists of several phases that are iterative, cyclical, and recursi linear and that are applied until clients’ needs and interests are met. The phases of the 

Screening

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Assessing Stratifying Risk Planning

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Implementing (Care Coordination) Following-Up

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Transitioning (Transitional Care) Communicating Post Transition Evaluating

Term Case managment plan of care

Description A comprehensive plan of care for an individual client that describes: 

The client’s problems, needs, and desires, as determined from the findings of t

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assessment. The strategies, such as treatments and interventions, to be instituted to address problems and needs.

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The measurable goals – including specific outcomes – to be achieved to demo resolution of the client’s problems and needs, the time frame(s) for achieving t resources available and to be used to realize the outcomes, and the desires/mo client that may have an impact on the plan (CMSA, 2016, p. 32).

Payor

The person, agency, or organization that assumes responsibility for funding the health services and resources consumed by a client. The payor may be the client him/herself the client’s support system, an employer, a government benefit program (e.g., Medica or TriCare), a commercial insurance agency, or a charitable organization.

Practice setting

(Also referred to as practice site, care setting, or work setting.) The organization or agency at which case managers are employed and execute their ro responsibilities. The practice of case management extends across all settings of the he human services continuum. These may include but are not limited to payor, provider, employer, community, independent/private, workers’ compensation, or a client’s hom

Professional discipline

Case managers’ formal education, training, and specialization or professional backgro necessary and prerequisite for consideration as health and human services practitioner to the professional background – such as nursing, medicine, social work, or rehabilita managers bring with them into the practice of case management.

Knowledge domain

A collection of information topics associated with health and human services and rela These topics are organized around common themes (domains) to form high-level/abst that are considered to be essential for effective and competent performance of case ma Examples of case management knowledge domains are Quality and Outcomes Evalua Measurement, and Care Delivery and Reimbursement Methods.

Health

An individual’s physical, functional, mental, behavioral, emotional, psychosocial, and condition. It refers to the presence or absence of illness, disability, injury, or limitation special management and resolution, including the use of health and human services-ty interventions or resources.

Term

Description NOTE: Throughout the CMBOK, the term health implies all aspects of health a the principal term, reflecting a wholistic view of the client’s condition or situatio

Health and human services continuum

The range of care that matches the ongoing needs of clients as they are served over tim Management Process and case managers. It includes the appropriate levels and types health, medical, financial, legal, psychosocial, and behavioral – across one or more ca The levels of care vary in complexity and intensity of healthcare services and resourc individual providers, organizations, and agencies. NOTE: Throughout the CMBOK, the term healthcare refers to and incorporate human services,” reflecting the broader community of professionals who serve c continuum of services they provide.

Level of care

The intensity and effort of health and human services and care activities required to di preserve, or maintain clients’ health. Level of care may vary from least to most compl most intense, or prevention and wellness to acute care and services.

Community services and resources

Healthcare programs that offer specific services and resources in a community-based as opposed to an institutional setting (i.e., outside the confines of healthcare facilities hospitals and nursing homes). These programs either are publicly or privately funded charitable in nature.

Benefit programs

The sum of services offered by a health insurance plan, government agency, or emplo individuals based on some sort of an agreement between the parties (e.g., employer an Benefits vary based on the plan and may include physician and hospital services, pres dental and vision care, workers’ compensation, long-term care, mental and behavioral disability and accidental death, counseling, and other therapies such as chiropractic ca

Benefits

The type of health and human services covered by a health insurance plan (sometimes health insurance benefits, health benefits, or benefits plan) and as agreed upon betwee company and an individual enrollee or participant. The term also refers to the amount insurance company to a claimant or beneficiary under the claimant's specific coverage in the health insurance plan.

Services

Interventions, medical treatments, diagnostics, and other activities implemented to ma conditions, including health and human services issues and needs. The types of servic implemented can be found in an individual client’s case management plan of care, me treatment plan, or other related documents as applicable to the healthcare setting and t professional discipline of the provider of care and services. NOTE: The term services is used generically in the CMBOK to include the vario care and services described above.

TheCaseManagementPr ocess TheCaseManagementPr oc es sc ons i s t sofni nephas est hr oughwhi c hc as emanager s pr ov i dec ar et ot hei rc l i ent s :Sc r eeni ng,As s es s i ng,St r at i f y i ngRi s k,Pl anni ng, I mpl ement i ng( Car eCoor di nat i on) ,Fol l owi ngUp,Tr ans i t i oni ng( Tr ans i t i onal Car e) , Communi c at i ngPos tTr ans i t i on,andEv al uat i ng.Theov er al l pr oc es si si t er at i v e,nonl i near ,andc y cl i cal ,i t sphas esbei ngr ev i s i t edasneces sar yunt i l t hedes i r edout c omei s achi ev ed.I tal s oi saffec t edbyt hec ar eset t i ngwher et hecl i entandc l i ent ’ ss uppor t s y s t em ar ebei ngcar edf orandt hepr act i c eset t i ngoft hec as emanager . Cent er i ngonac l i entandt hec l i ent ’ ss uppor ts y s t em,t heCaseManagementPr oc es si s whol i s t i ci ni t sappr oac ht ot hemanagementoft hec l i ent ’ ss i t uat i onandt hatoft he c l i ent ’ ss uppor ts y s t em.I ti sadapt i v ebot ht ot hec as emanager ’ spr ac t i c es et t i ngandt o t heheal t hc ar es et t i ngi nwhi c ht hec l i entr ec ei v ess er v i ces .

TheHi ghLevelCaseManagementPr ocess

Vi ewl ar geri mage

Cas emanager snav i gat et hephasesoft hepr oc es swi t hcar ef ulc ons i der at i onoft he c l i ent ’ sc ul t ur al bel i ef s ,i nt er es t s ,wi s hes ,needs ,andv al ues.Byf ol l owi ngt hes t eps,t hey hel pc l i ent s / s uppor ts y s t emst o: 

Ev al uat eandunder s t andt hecar eopt i onsav ai l abl et ot hem

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Agr eeont hei rc ar egoal sandpr i or i t i es

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Det er mi newhati sbes tt omeett hei rneeds I ns t i t ut eac t i ont oac hi ev et hei rgoal sandmeett hei ri nt er es t s/ ex pec t at i ons

Att hes amet i me,c as emanager sappl y : 

Rel ev ants t at eandf eder al l aws

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Et hi c al pr i nci pl esands t andar dss uc hast heCCMC’ sCodeofPr of es s i onal

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Conductf orCas eManager swi t hSt andar ds ,Rul es ,Pr ocedur es ,andPenal t i es ( CCMC,2015) ,whi c happl i est oper s onshol di ngt heCCM®c r edent i al Ac c r edi t at i onandr egul at...