FUNDAMENTALS OF CASE/CARE MANAGEMENT 2

Fundamentals of Case/Care Management

Case management can be defined as the collaborative process of ensuring that a patient’s
and a family’s healthcare needs are met through communication and effective use of available
resources. In nursing, case management involves a collaborative approach of delivering
healthcare services to a specific population. Healthcare is dynamic in nature, and case managers
have to ensure that they integrate the changes in their responsibilities. The role of a case manager
must, however, be patient-centered (Rossi, 2014). Case managers must coordinate for the
mobilization of resources to meet the patient’s present and future anticipated needs. Case
managers must also ensure that they collaborate with physicians in order to ensure that patients
get the right care as well as facilitate correct reimbursement while minimizing payment denials.
Nursing case managers lead a multidisciplinary team that includes various healthcare
professionals and work towards eliminating the barriers to care and timely discharge.
In the hospital setup, staff members who play the role of coordination, discharge, and
planning are considered case managers. The goals of case managers include ensuring high
quality and cost-effective clinical outcomes (Rossi, 2014). The goal of ensuring quality and cost-
effective clinical outcomes is met through efficient utilization of available resources. Case
managers also work towards a reduction in costs through striking a balance in the utilization of
resources necessary to achieve realistic clinical outcomes (Rossi, 2014). Case managers also
work closely with the patients to ensure that the right care is given and the length of stay is as
brief as possible.
Achieving the goals of a case manager requires one to have various competencies. One
competency required for a case manager is the ability to carry out accurate assessments for

FUNDAMENTALS OF CASE/CARE MANAGEMENT 3
interventions. A case manager must also ensure that they develop plans that can be executed by a
multidisciplinary care team. The setting of healthcare goals is also an important competency. The
Case Management Society of America (CMSA) has outlined five competencies for case
managers (Rossi, 2014). The competencies include the ability to evaluate physical and
psychological factors that surround a case, ability to play a role in the coordination of service
delivery, nursing practice knowledge, and knowledge on community resources. A case manager
must have the knowledge and understanding of the provisions of an insurer. A case manager
must also possess unique communication skills that include both written and oral (Rossi, 2014).
Case managers must possess problem-solving skills as well as age-specific competencies. Time
management is also key in case management. Creativity and flexibility help a case manager to
solve the problems encountered in the healthcare setting and also help patients and caregivers to
meet the healthcare goals and expectations.
For one to be a successful case manager, there are other skills required. A case manager
must have the appropriate clinical knowledge. The implication is that one needs to have
knowledge of pathophysiology, anatomy, and pharmacology (Tahan, & Treiger, 2016). Case
managers work in a team, and this means that a case manager must be a team player and must
ensure that they can efficiently delegate certain roles and responsibilities (Tahan, & Treiger,
2016). Conflicts may occur when teams are executing their functions. A case manager must
ensure that they can resolve the conflicts that occur and hence enhance service delivery. Case
managers must have the ability to say no. They must also be committed to meeting healthcare
goals and must be self-motivated.
Healthcare is affected by various factors. One of the factors that affect the delivery of
healthcare is applicable laws. Case managers must be knowledgeable about laws that affect the

FUNDAMENTALS OF CASE/CARE MANAGEMENT 4
delivery of healthcare services. Case managers must ensure that they understand Medicare,
Medicaid as well as other applicable laws, including the Health Insurance and Portability Act
(HIPAA) and Emergency Medical Treatment and Labor Act (EMTALA). Case managers must
have a deeper understanding of the state laws that relate to the reporting of abuse. In case there is
a threat of litigation against a hospital or healthcare setting, case managers must ensure that they
try to diffuse the situation while remaining calm (Tahan, & Treiger, 2016). It is also important
that the case manager minimize the threat of litigation through practices such as ensuring that
providers have the necessary licenses. Case managers, like other healthcare professionals, are
bound by standards of care. Standards of care outline the minimal level of care that must be
delivered to patients (Tahan, & Treiger, 2016). Standards of care can either be external or
external. Case managers must uphold the standards of care that are part of the nursing profession.
Adherence to these standards helps ensure that all patients get quality and competent care.

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References

Rossi, P. (2014). The hospital case management orientation manual. Danvers, MA: HCPro, a
division of BLR.
Tahan, H. M., & Treiger, T. M. (2016). CMSA Core Curriculum for Case Management: Vol. 3rd
ed. Wolters Kluwer Health

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Appendix: Job Description

Job Summary
Nursing case management involves the coordination of healthcare services to patients.
RN case managers evaluate and implement healthcare plans for individual patients. They help
ensure that patients have access to effective and efficient medical care while ensuring that the
cost of healthcare service delivery is minimized. An RN case manager also plays the role of
linking patients and their families to doctors and other healthcare specialists.
Roles and Responsibilities
The jobs and responsivities include:
 Assessment of new patients.
 Coordinating the development, implementation and linkage of resources to meet the
existing and future healthcare needs.
 Collaboration with physicians to ensure that patients are at the right level of care.
 Correcting reimbursement and minimizing payment denials.
 Reviewing and determining patient needs.
 Documenting and submitting accurate medical records.
 Making key decisions with regard to clinical care and routine patient care.
Skills Needed
The following are the skills needed:
 Teamwork

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 Conflict resolution
 Organizational skills
 Time management
 Decision-making skills
 Problem-solving skills
 Commitment and self-motivation
 Communication skills
 Age-specific competencies
 Awareness of potential literacy issues
 Flexibility and creativity
 Legal knowledge
Education and Qualifications
For one to be a case manager, they must have a registered nurse (RN) license. One must,
therefore be a holder of a bachelor of science nursing (BSN) or a holder of an associate’s
degree in nursing (ADN). In addition to a bachelor or an associate’s degree in nursing, one
must also have passed the NCLEX-RN examination. The exam allows one to be a registered
nurse. One must also have at least two years’ experience as a registered nurse. Case
management certification is also recommended to ensure that one enhances their
competencies. One must demonstrate knowledge in the various nursing field as well as the
ability to work closely with patients and their families.