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Case Management Society of America

Part 4: Case Management Society of America
Issues Revised Standards of Practice –
Professional Case Management
Roles and Responsibilities
The Case Management Society of America (CMSA) has issued revised Standards of Practice for Case Management. The Standards were first published in 1995 and were revised in 2002 and 2010. The general purpose of the Standards is to identify important knowledge and skills for case managers, regardless of practice setting. CMSA decided to revise the Standards again this year in order to emphasize the professional nature of the practice, and role of case managers as an integral and necessary component of the health care delivery system. These standards likely apply to all case managers, regardless of practice setting or whether they are certified case managers.

Case managers generally perform primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation and advocacy. Collaboration and ongoing communication with clients, clients’ families and caregivers and other health professionals involved in clients’ care are integral to the functions of case managers.

Recent revisions to CMSA’s standards state that specific functions of case managers may include, but are not limited to, the following:

Considering predictive modeling, screening and other data to determine whether clients may benefit from case management services

Conducting assessments of clients’ health, physical, functional behavioral, and psychological and social needs that direct development and implementation of specific plans of care

Identifying target goals for care in collaboration with clients, clients’ families and caregivers, and other members of the health care team

Planning care interventions and needed resources with clients, families or family caregivers, providers, payors and community-based services to maximize clients’ health care responses, quality, safety, cost-effective outcomes and optimal care experiences

Facilitating communication and coordination among members of the interprofessional health care team, including involving clients in decision-making processes, in order to minimize fragmentation in services provided and prevention of unsafe care and suboptimal outcomes

Collaborating with other health care professionals and support services providers across care settings, levels of care and professional disciplines in order to help ensure safe transitions of care

Coordinating care interventions, referrals to specialty providers and community-based support services, consults and resources across practitioners and care settings

Communicating continuously with clients, their families and caregivers and others involved in clients’ care to help ensure that they are well-informed and current on plans of care

Educating clients, their families and caregivers, and members of the health care team about treatment options, community resources, health insurance benefits, psychosocial and financial concerns, and case management services in order to make timely and informed decisions

Counseling and empowering clients to solve problems by exploring options of care and alternative plans to achieve desired outcomes

Completing notifications for and pre-authorization of services, medical necessity reviews and concurrent or retrospective communications based on payors’ requirements, and utilization management procedures

Ensuring appropriate allocation, use and coordination of services and resources while striving to improve safety and quality of care, and maintaining cost effectiveness

Identifying and addressing barriers to care and clients’ engagement in their own health

Assisting clients to achieve safe care transitions

Promoting self-advocacy by clients, independence and self-determination, and provision of client-centered and culturally appropriate care

Advocating for both clients and payors to facilitate positive outcomes except, when a conflict arises, the needs of clients must be the “number one priority”

Evaluating the effectiveness of plans of care, resource allocation and service provision while applying outcome measures reflective of organization policies and expectations, accreditation standards and regulatory requirements

Engaging in performance improvement activities to improve clients’ access to timely care and services, and enhancing the achievement of goals and desired outcomes

Based upon the above description of the roles and responsibilities of case managers, it is clear that they play a crucial role in the healthcare delivery system.

©2016 Elizabeth E. Hogue, Esq.  All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.