Standards of Practice
for Case Management
Revised 2010
The Evolution of the Standards
The Denition of Case Management
Philosophy and Guiding Principles
Case Management Practice Settings
Components of the Process
Standards of Case Management
Acknowledgements and Glossary
Standards of Practice for
Case Management, Revised 2010
©
CMSA Standards of Practice for Case Management
1
Case Management
Society of America
6301 Ranch Drive
Little Rock, Arkansas 72223
T 501.225.2229
F 501.227.5444
E [email protected]
www.cmsa.org
CASE MANAGEMENT SOCIETY
OF AMERICA
Standards of Practice
for Case Management,
Revised 2010©
© 2010 All rights reserved.
Table of Contents
Foreword ............................................................................2
Preface ...............................................................................3
I. INTRODUCTION ..................................................................4
II. EVOLUTION OF THE STANDARDS OF PRACTICE
FOR CASE MANAGEMENT ..................................................6
A. Standards of Practice for Case Management (1995) ........6
B. Standards of Practice for Case Management (2002) ........6
C. Standards of Practice for Case Management (2010) ........7
III. DEFINITION OF CASE MANAGEMENT ................................8
IV. PHILOSOPHY AND GUIDING PRINCIPLES ...........................9
A. Statement of Philosophy .................................................9
B. Guiding Principles ...........................................................9
V. CASE MANAGEMENT PRACTICE SETTINGS .......................11
VI. CASE MANAGEMENT ROLES, FUNCTIONS,
AND ACTIVITIES ...............................................................12
VII. COMPONENTS OF THE CASE MANAGEMENT PROCESS ...14
VIII. STANDARDS OF CASE MANAGEMENT PRACTICE .............15
A. Client Selection Process for Case Management ............15
B. Client Assessment ........................................................15
C. Problem/OpportunityIdentication ..............................16
D. Planning ......................................................................16
E. Monitoring ...................................................................17
F. Outcomes ....................................................................17
G. Termination of Case Management Services ..................17
H. Facilitation, Coordination, and Collaboration ...............18
I. QualicationsforCaseManagers .................................19
J. Legal ............................................................................19
1. CondentialityandClientPrivacy ............................19
2. Consent for Case Management Services ..................19
K. Ethics ...........................................................................20
L. Advocacy .....................................................................20
M. Cultural Competency ....................................................21
N. Resource Management and Stewardship ......................21
O. Research and Research Utilization ................................22
IX. ACKNOWLEDGEMENTS ....................................................23
X. GLOSSARY ........................................................................24
References ........................................................................27
Foreword
It is our pleasure to present the 2010 revision of the Case Management Society of America’s
(CMSA)
Standards of Practice for Case Management
(SoP).TheseStandardswererstpublished
in 1995 and revised in 2002. Today, as our nation faces ever-changing challenges to our health
care system, CMSA recognized the need to revise the
Standards of Practice
tobemorereec-
tive of the rapidly growing and expanding role of case managers and the increased awareness
of case managers as crucial members of the health care team. These key issues, among others,
providedtheimpetustore-examineandredeneourroleinthecurrenthealthcarematrix.
Asourprolebecomesevermorevisible,itiscriticalthatweexamineourselvesandset
standards by which we must be held accountable. Among the many changes to this edition,
oneofspecialnoteistherevisedqualicationslanguage.Toestablishourpositionasproviders
of service and to improve our position for reimbursement of case management services, it is
imperativetoestablishacceptedqualicationsforcasemanagers.Equallyimportant,itises-
sential to validate our positive outcomes as we work with patients through case management
interventions.Ultimately,byclarifyingourqualicationsandvalidatingoutcomesachieved,the
Standards of Practice
will strengthen the case management professional.
This edition of the
Standards of Practice
is the product of many hours of labor, research,
and deliberation among those who served on the task force, reference committees, case
managers at-large, and the CMSA Board of Directors, who ultimately approves the
Standards
of Practice
. There are many people to thank for their role in this revision. First, we must
acknowledge Peter Moran who had the wisdom to call for the revision during his presidency
and the foresight to ask Carrie Marion to lead the task force. We would also like to recognize
the efforts of Cheri Lattimer and Danielle Marshall who have shepherded and supported the
project over the past two years.
Lastly, we would like to thank you, the case managers, for providing service to those in
need, and for being part of “what is right” in health care through your passion and commit-
ment.
The time from conception to fruition of this edition of our
Standards of Practice
has
spanned three CMSA presidencies, and we are grateful to have been part of this historic
moment-in-time for case managers and CMSA.
Jeff Frater, RN, BSN, CMSA President (2008 – 2009)
Margaret “Peggy” Leonard, MS, RN-BC, FNP, CMSA President (2009 – 2010)
2
CMSA Standards of Practice for Case Management
CMSA Standards of Practice for Case Management
3
Preface
T
he
Standards of Practice for Case Management
wererstintroducedbytheCMSAin
1995 and then revised in 2002. We are pleased to offer the
Standards of Practice for
Case Management
, 2010 revision, which provides voluntary practice guidelines for the
case management industry. The Standards of Practice are intended to identify and address
important foundational knowledge and skills of the case manager within a spectrum of case
management practice settings and specialties.
The2010Standardsreectmanychangesintheindustry,whichresonatewithcurrent
practice today. Some of these changes include the following:
Minimizing fragmentation in the health care system, using evidence-based guidelines in
practice, navigating transitions of care, incorporating adherence guidelines and other stan-
dardized practice tools, expanding the interdisciplinary team in planning care for individuals,
and improving patient safety.
We believe that these are all important factors that case managers need to address in
their practices. The 2010
Standards of Practice
contain information about case management
practice,includingdenition,practicesettings,roles,functions,activities,casemanagement
process, philosophy and guiding principles, as well as the standards and how they are dem-
onstrated. This document is intended for voluntary use and is not intended to replace relevant
legal or professional practice requirements.
The 2010
Standards of Practice
were developed through the efforts of dedicated case
managers who spent countless hours synthesizing information over two public comment peri-
ods to develop this document.
The teams include:
(1) Acoretaskforcemadeupofrepresentativesofthecasemanagementeldinvarious
practice settings and disciplines
(2) A larger reference group that included the CMSA leadership and Board of Directors,
legal advisors, and the case management industry
(3) Other case management experts in the industry
(4) Case managers at-large during the Public Comment period
It has been my pleasure to work on this project with the talented and committed individu-
alswhoareraisingthebarofexcellenceintheeldofcasemanagement.
Carrie Marion, RN, BSN, CCM
Committee Chair
The consistent delivery of quality health care
servicesandthehighnancialcostgenerally
associated with those services are important
concerns that touch everyone, from our
leaders in Washington, D.C. to the American
public.
Payers
continue to seek methods for
reducing costs while advancing quality and
transparency.
Providers
explore methods to
deneandreportqualitywhilemaximizingre-
imbursement. Too frequently, the health care
consumer
is left to navigate the health care
system without the tools, resources, support
or education that are vital to this role.
Although a number of strategies for
health care reform have been espoused and
debated, case management has emerged as
an important intervention that fosters the
careful shepherding of health care dollars
while maintaining a primary and consistent
focus on quality of care and client self-deter-
mination.
Founded in 1990, the CMSA is the lead-
ingnon-protassociationdedicatedtothe
support and development of case manage-
ment. The strategic
Vision
of CMSA approved
in 2009 is as follows:
Case managers are recognized
experts and vital participants in the
care coordination team who empower
people to understand and access qual-
ity, efcient health care.
To complement this Vision, case manage-
ment practitioners, educators and leaders
have come together to reach consensus
regarding the guiding principles and funda-
mental spirit of the practice of case manage-
ment. As initially presented and with each
subsequent revision, the
Standards of Practice
for Case Management
have been based on an
understanding that case management is not
aspecichealthcareprofession,butrather
an advanced practice within the varied health
4
CMSA Standards of Practice for Case Management
I. Introduction
care professions that serves as a founda-
tion for case management. Therefore, the
Standards described within this document are
not intended to be a structured recipe for the
delivery of case management interventions.
Rather, they are offered to present a range
of core functions, roles, responsibilities, and
relationships that are integral to the practice
of case management.
The nature of the written word has
limitationsanddenitionsusedinthe
Standards required much discussion. With the
exception of the Continuum of Health Care
gure(Seepage5)wheretwoterms(client
andpatient)arereected,
the word “client”
is used throughout these Standards to mean
the recipient of case management services
.
Thisindividualmaybeapatient,beneciary,
injured worker, claimant, enrollee, member,
college student, resident, or health care
consumer of any age group. However, “client”
can also mean something very different than
the end-user of case management services; a
client can also imply the business relationship
with a company who contracts, or pays, for
case management services.
Tofurtherdenetherecipientsofcase
management interventions, the term “
sup-
port system”
is used. This
support system
isdenedbyeachclientandmayinclude
biological relatives, spouses, partners, friends,
neighbors, colleagues, or any individual who
supports
the client. Note that sometimes
when using the term “client,” it may also be
inclusive of the client’s support system.
Another decision made was use of
case
management, rather than
care
manage-
ment.Thesetwotermsarefurtherdenedin
the Glossary, but for consistency, case man-
agement is used throughout this document.
Some adjustments may be necessary
as these Standards are incorporated into
individual practices. For example, where
these Standards used the word “client,” you
may choose to substitute
resident, consumer,
beneciary,individual,
or another term.
While the Standards are offered to
standardize the process of case management,
they are also intended to be realistically
attainable by individuals who use appropri-
ate and professional judgment regarding the
delivery of case management services
to targeted client populations.
Additionally, the Standards may serve to
present a portrait of the scope of case man-
agement practice to our colleagues and to the
health care consumers that work in partner-
ship with the case management professional.
CMSA Standards of Practice for Case Management
5
The Continuum of Health Care
II. Evolution of the Standards
of Practice for Case Management
A.
Standards of Practice
for Case Management
(1995)
In 1995, the President of the CMSA wrote
a foreword in the 1995
CMSA Standards of
Practice
. In it he stated that the
“development
of national Standards represents a major step
forward for case managers. The future of our
practice lies in the quality of our performance,
as well as our outcomes”
(CMSA, 1995, pg.3).
TheserstStandardsincludedthisdenition
of case management (CMSA, 1995, pg.8):
Case management is a collabora-
tive process which assesses, plans,
implements, coordinates, monitors and
evaluates options and services to meet
an individual’s health needs through
communication and available resourc-
es to promote quality cost-effective
outcomes.
The 1995
Standards of Practice
were
recognized as an anticipated tool that case
management would utilize within every case
management practice arena. They were
seen as a guide to move case management
practice to excellence. The Standards explored
the planning, monitoring, evaluating and
outcomes phases, followed by Performance
Standards for the practicing case manager.
The Performance Standards addressed how
the case manager worked within each of the
established Standards and with other disci-
plines to follow all legal requirements.
Evenatthisrstjuncture,theStandards
committee recognized the importance of
the case managers basing their individual
practiceonvalidresearchndingsandthey
encouraged case managers to participate in
the research process, programs, and develop-
mentofspecictoolsforthepracticeofcase
management. This was evidenced by key sec-
tions that highlighted measurement criteria in
the collaborative, ethical, and legal sections
(CMSA, 1995).
B.
Standards of Practice
for Case Management
(2002)
The 2001 Board of Directors for CMSA
identiedtheneedforacarefulandthorough
review and, if appropriate, revision of the
initial published Standards. The revised
Stan-
dards of Practice for Case Management
were
publishedin2002.Thepublisheddenitionof
case management was amended to (CMSA,
2002, pg. 5):
Case management is a collabora-
tive process of assessment, planning,
facilitation and advocacy for options
and services to meet an individual’s
health needs through communication
and available resources to promote
quality cost-effective outcomes.
The section on Performance Indicators
wasexpandedtofurtherdenethecase
manager. The purpose of case management
was revised to address quality, safety and
cost-effective care, as well as to focus upon
facilitating appropriate access to care.
Primary case management functions in
2002 included both current and new skills
and concepts: positive relationship-building;
effective written/verbal communication; ne-
gotiation skills; knowledge of contractual and
risk arrangements, the importance of obtain-
ingconsent,condentiality,andclientprivacy;
attention to cultural competency; ability to
effect change and perform ongoing evalua-
tion; use of critical thinking and analysis; abil-
ity to plan and organize effectively; promote
client autonomy and self-determination; and
knowledge of funding sources, health care
services, human behavior dynamics, health
caredeliveryandnancingsystems,andclini-
cal standards and outcomes.
6
CMSA Standards of Practice for Case Management
Case management work applied to indi-
vidual clients or to groups of clients, such as
in disease management or population health
models. The facilitation section included more
detail about the importance of communica-
tion and collaboration on behalf of the client
and the payer. The practice settings for case
management were increased to capture the
evolution of, and the increase in, the number
of venues in which case managers worked.
C.
Standards of Practice for
Case Management
(2010)
The
Standards of Practice for Case Manage-
ment
2010includetopicsthatinuencethe
practice of case management in the current
health care environment. Included in this
revision are:
Addressing the total individual, inclusive
of medical, psychosocial, behavioral, and
spiritual needs.
Collaborating efforts that focus upon
moving the individual to self-care when-
ever possible.
Increasing involvement of the individual
and caregiver in the decision-making
process.
Minimizing fragmentation of care within
the health care delivery system.
Using evidence-based guidelines, as
available, in the daily practice of case
management.
Focusing on transitions of care, which
includes a complete transfer to the next
care setting provider that is effective,
safe, timely, and complete.
CMSA Standards of Practice for Case Management
7
Improving outcomes by utilizing adher-
ence guidelines, standardized tools, and
proven processes to measure a client’s
understanding and acceptance of the
proposed plans, his/her willingness to
change, and his/her support to maintain
health behavior change.
Expanding the interdisciplinary team to
includeclientsand/ortheiridentied
support system, health care providers,
including community-based and facility-
based professionals (i.e., pharmacists,
nurse practitioners, holistic care provid-
ers, etc.).
Expanding the case management role to
collaborate within one’s practice setting
to support regulatory adherence.
Moving clients to optimal levels of health
and well-being.
Improving client safety and satisfaction.
Improving medication reconciliation for a
client through collaborative efforts with
medical staff.
Improving adherence to the plan of
care for the client, including medication
adherence.
These changes advance case manage-
ment credibility and complement the current
trends and changes in health care. Future
case management
Standards of Practice
will
likelyreecttheexistingclimateofhealthcare
and build upon the evidence-based guidelines
that are proven successful in the coming years.
8
CMSA Standards of Practice for Case Management
III.DenitionofCaseManagement
The basic concept of case management
involves the timely coordination of quality
servicestoaddressaclient’sspecicneeds
in a cost-effective manner in order to promote
positive outcomes. This can occur in a single
health care setting or during the client’s tran-
sitions of care throughout the care continuum.
The case manager serves as an important
facilitator among the client, family or care-
giver, the health team, the payer, and the
community.
As demonstrated in the section on the
Evolution of the Standards of Case Manage-
ment
,thedenitionofcasemanagement
hasevolvedoveraperiodoftime;itreects
the vibrant and dynamic progression of the
standards of practice.
Following more than a year of study and
discussion with members of the National Case
Management Task Force, the CMSA’s Board
ofDirectorsapprovedadenitionofcase
management in 1993.
Since that time, the CMSA Board of Di-
rectors has repeatedly reviewed and analyzed
thedenitionofcasemanagementtoensure
its continued application in a dynamic health
environment.Thedenitionwasmodiedin
2002toreecttheprocessofcasemanage-
ment outlined within the Standards. The
denitionwasagainrevisitedin2009and
modiedtofurtheralignwiththecurrent
practice of case management.
Whiletherearemanydenitionsofcase
management,the2009denitionapproved
by CMSA is as follows (CMSA, 2009):
Case management is a collabora-
tive process of assessment, planning,
facilitation, care coordination, evalu-
ation, and advocacy for options and
services to meet an individual’s and
family’s comprehensive health needs
through communication and available
resources to promote quality cost-
effective outcomes.
CMSA Standards of Practice for Case Management
9
IV. Philosophy and Guiding Principles
A. Statement of Philosophy
A philosophy is a statement of belief that sets
forth principles to guide a program and the
individual in his/her practice of that program
(Powell & Tahan, 2008). The CMSA’s philoso-
phy of case management statement articu-
lates that (CMSA, 2009):
The underlying premise of case
management is based in the fact that,
when an individual reaches the opti-
mum level of wellness and functional
capability, everyone benets: the
individuals being served, their support
systems, the health care delivery sys-
tems and the various reimbursement
sources. Case management serves as
a means for achieving client wellness
and autonomy through advocacy,
communication, education, identica-
tion of service resources and service
facilitation. ... Case management
services are best offered in a climate
that allows direct communication
between the case manager, the client,
and appropriate service personnel, in
order to optimize the outcome for all
concerned.
The philosophy of case management
underscores the recommendation that in-
dividuals, particularly those experiencing cata-
strophic injuries or severely chronic illnesses,
be evaluated for case management services.
The key philosophical components of case
management address care that is holistic and
client-centered, with mutual goals, allowing
stewardship of resources for the client and
the health care system. Through these efforts,
case management focuses simultaneously on
achieving health and maintaining wellness to
the highest level possible for each client.
It is the philosophy of case manage-
ment that when health care is appropriately
andefcientlyprovided,allpartiesbenet.
The provision of case management, working
collaboratively with the health care team in
complex situations, serves to identify care
options which are acceptable to the client.
This will, in turn, increase adherence to the
plan of care and successful outcomes. Case
management reduces the fragmentation of
care, which is too often experienced by clients
who obtain health care services from multiple
providers. Taken collectively, services offered
by a case manager can enhance a client’s
safety, well-being and quality of life, while
reducing total health care costs. Thus, effec-
tive case management can directly and posi-
tively affect the health care delivery system.
B. Guiding Principles
Guiding principles are relevant and meaning-
ful concepts that clarify or guide practice.
Guiding principles for case management prac-
tice include the following. Case managers:
Use a client-centric, collaborative
partnership approach.
Whenever possible, facilitate self-
determination and self-care through
the tenets of advocacy, shared decision-
making, and education.
Use a comprehensive, holistic approach.
Practice cultural competence, with
awareness and respect for diversity.
Promote the use of evidence-based care,
as available.
Promote optimal client safety.
Promote the integration of behavioral
change science and principles.
10
CMSA Standards of Practice for Case Management
Link with community resources.
Assist with navigating the health care
system to achieve successful care, for
example during transitions.
Pursue professional excellence and main-
tain competence in practice.
Promote quality outcomes and measure-
ment of those outcomes.
Support and maintain compliance with
federal, state, local, organizational, and
certicationrulesandregulations.
Case management guiding principles,
interventions, and strategies are targeted at
the achievement of client stability, wellness,
and autonomy through advocacy, assessment,
planning, communication, education, resource
management, care coordination, collabora-
tion, and service facilitation.
They are based on the needs and
values of the client and are accomplished
in collaboration with all service providers.
This accomplishes care that is appropriate,
effective,client-centered,timely,efcient,and
equitable.
CMSA Standards of Practice for Case Management
11
V. Case Management Practice Settings
Case management practice extends across all
health care settings, including payer, provider,
government, employer, community, and home
environment. However, the practice varies in
degrees of complexity and comprehensiveness
based on the following four factors (Powell
and Tahan, 2008):
1. The context of the care setting, such
as wellness and prevention, acute, or
rehabilitative.
2. The health conditions and needs of the
patient population(s) served, as well as
the needs of the family/caregivers, such
as critical care, asthma, renal failure,
hospice care.
3. The reimbursement method applied, such
as managed care, workers’ compensa-
tion, Medicare, or Medicaid.
4. The health care professional discipline
designated as the case manager, such as
registered nurse, social worker, physi-
cian, rehabilitation counselor, etc.
The following is a representative list of
case management practice settings; however,
it is not an exhaustive list of settings where
case managers exist. Case managers work in:
Hospitals and integrated care delivery
systems, including acute care, sub-
acute care, long-term acute care (LTAC)
facilities, skilled nursing facilities (SNF),
rehabilitation facilities.
Ambulatory care clinics and community
based organizations, including student/
university counseling and health care
centers.
Corporations.
Public health insurance programs, e.g.,
Medicare, Medicaid, state-funded programs.
Private health insurance programs,
e.g., workers’ compensation, occupation-
al health, disability, liability, casualty,
automotive, accident and health, long-
term care insurance, group health
insurance, managed care organizations.
Independent and private case manage-
ment companies.
Government-sponsored programs,
e.g., correctional facilities, military
health care/Veterans Administration,
public health.
Provider agencies and community facili-
ties, i.e., mental health facilities, home
health services, ambulatory and day care
facilities.
Geriatric services, including residential
and assisted living facilities.
Long-term care services, including home
and community based services.
Hospice, palliative, and respite care
programs.
Physician and medical group practices.
Life care planning programs.
Disease management companies.
VI. Case Management Roles, Functions,
and Activities
It is necessary to differentiate between the
terms “role,” “function,” and “activity,” before
describingwhatcasemanagersdo.Dening
these terms is essential to providing a clear
and contextual understanding of the roles and
responsibilities of case managers.
A
role
is a general and abstract term
that refers to a set of behaviors and expected
consequences that are associated with one’s
position in a social structure. A
function
is a
groupingofasetofspecictaskswithinthe
role. An
activity
is a discrete action or task a
person performs to address the expectations
of the role assumed (See Glossary).
A role tends to consist of several func-
tions and each function is described through
alistofspecicactivities.Thesedescriptions
constitute what is known as a “job descrip-
tion.” The roles assumed by case managers
vary based on the same four factors described
in the section entitled,
Case Management
Practice Setting
.
The case manager performs the primary
functions of assessment, planning, facilitation
and advocacy, which are achieved through
collaboration with the client and other health
care professionals involved in the client’s
care. Key responsibilities of case management
havebeenidentiedbynationallyrecognized
professional societies and certifying bodies
through case management roles and functions
research.
It is not the intent of the Standards
to parallel these key responsibilities; the
Standardswillbroadlydenemajorfunctions
involved in the case management process to
achieve desired outcomes.
Successful outcomes cannot be achieved
without specialized skills and knowledge
applied throughout the process. These skills
include, but are not limited to, positive rela-
tionship-building; effective written and verbal
communication; negotiation; knowledge of
contractual or risk arrangements; the ability
to effect change, perform ongoing evaluation
and critical analysis; and the ability to plan
and organize effectively.
It is important for the case manager to
have knowledge of funding sources, health
care services, human behavior dynamics, the
healthcaredeliveryandnancingsystems,
and clinical standards and outcomes. The
skills and knowledge base of a case manager
may be applied to individual clients, or to
groups of clients, such as in disease manage-
ment or population health models.
Role functions of case managers include:
Conducting a comprehensive assessment
of the client’s health and psychosocial
needs, including health literacy status
anddecits,anddevelopsacaseman-
agement plan collaboratively with the
client and family or caregiver.
Planning with the client, family or
caregiver, the primary care physician/
provider, other health care providers, the
payer, and the community, to maximize
health care responses, quality, and cost-
effective outcomes.
Facilitating communication and coordi-
nation between members of the health
care team, involving the client in the
decision-making process in order to
minimize fragmentation in the services.
Educating the client, the family or care-
giver, and members of the health care
delivery team about treatment options,
communityresources,insurancebenets,
psychosocial concerns, case manage-
ment, etc., so that timely and informed
decisions can be made.
12
CMSA Standards of Practice for Case Management
Empowering the client to problem-solve
by exploring options of care, when
available, and alternative plans, when
necessary, to achieve desired outcomes.
Encouraging the appropriate use
of health care services and strives
to improve quality of care and
maintain cost effectiveness on
a case-by-case basis.
Assisting the client in the safe
transitioning of care to the next
most appropriate level.
Striving to promote client self-advocacy
and self-determination.
Advocating for both the client and the
payer to facilitate positive outcomes for
the client, the health care team, and the
payer.However,ifaconictarises,the
needs of the client must be the priority.
CMSA Standards of Practice for Case Management
13
VII. Components of the
Case Management Process
The case management process is carried out
within the ethical and legal realm of a case
manager’s scope of practice, using critical-
thinking and evidence-based knowledge. The
overarching themes in the case management
process include the tasks described below.
However, note that case management
is neither linear nor a one-way exercise. For
example, the
assessment
responsibilities
will occur at all points in the process, and
functions such as
facilitation, coordination,
and
collaboration
will occur throughout the
client’s health care encounter.
Primary steps in the case management
process include (Powell & Tahan, 2008):
1.
Clientidenticationandselection:
Focuses on identifying clients who would
benetfromcasemanagementservices.
This step may include obtaining consent
for case management services, if
appropriate.
2.
Assessment and problem/opportunity
identication:
Begins after the comple-
tion of the case selection and intake into
case management and occurs intermit-
tently, as needed, throughout the case.
3.
Development of the case management
plan:
Establishes goals of the interven-
tion and prioritizes the client’s needs,
as well as determines the type of services
and resources that are available in order
to address the established goals or
desired outcomes.
4.
Implementation and coordination
of care activities:
Puts the case manage-
ment plan into action.
5.
Evaluation of the case management plan
and follow-up:
Involves the evaluation
of the client’s status and goals and the
associated outcomes.
6.
Termination of the case management
process:
Brings closure to the care and/or
episode of illness. The process focuses on
discontinuing case management when
the client transitions to the highest level
of function, the best possible outcome
has been attained, or the needs/desires
of the client change.
14
CMSA Standards of Practice for Case Management
VIII. Standards of Case Management
Practice
A. STANDARD:
CLIENT SELECTION PROCESS
FOR CASE MANAGEMENT
The case manager should identify and select
clientswhocanmostbenetfromcaseman-
agement services available in a particular
practice setting.
How Demonstrated:
Documentation of consistent use of the
selection process within the individual
organization’s policies and procedures.
Use of high-risk screening criteria to
assess for inclusion in case manage-
ment programs. Examples of high-risk
screening criteria include, but are not
limited to:
Age•
Poor pain control•
Low functional status or cognitive •
decits
Previous home health and durable •
medical equipment usage
History of mental illness or substance •
abuse, suicide risk, or crisis interven-
tion
Chronic, catastrophic, or terminal •
illness
Social issues such as a history of •
abuse, neglect, no known social
support, or lives alone
Repeated emergency department •
visits
Repeated admissions •
Need for admission or transition •
to a post-acute facility
Poor nutritional status•
Financial issues•
B. STANDARD:
CLIENT ASSESSMENT
The case manager should complete a health
and psychosocial assessment, taking into
account the cultural and linguistic needs of
each client.
How Demonstrated:
Documentation of client assessments
using standardized tools, when ap-
propriate. Example criteria may include,
but are not limited to the following
components (as pertinent to the case
manager’s practice setting):
Physical/functional•
Medical history•
Psychosocial behavioral •
Mental health•
Cognitive•
Client strengths and abilities•
Environmental and residential •
Family or support system dynamics •
Spiritual •
Cultural •
Financial •
Health insurance status•
History of substance use•
History of abuse, violence, •
or trauma
Vocational and/or educational •
Recreational/leisure pursuits •
Caregiver(s) capability •
and availability
Learning and technology •
capabilities
Self-care capability•
Health literacy•
Health status expectations and goals •
Transitional or discharge plan •
Advance care planning•
Legal •
CMSA Standards of Practice for Case Management
15
Transportation capability and con-•
straints
Health literacy and illiteracy•
Readiness to change•
Documentation of resource utiliza-
tion and cost management; current
diagnosis(es); past and present course
and services; prognosis; goals (short and
long term); provider options; and avail-
ablehealthcarebenets.
Evidence of use of relevant, comprehen-
sive information and data required for
client assessment from many sources
including, but not limited to:
Client interviews•
Initial assessment and ongoing •
assessments
Family or caregivers, physicians, •
providers, other members of the inter-
disciplinary health care team
Medical records•
Data: claims and or administrative•
C. STANDARD:
PROBLEM/OPPORTUNITY
IDENTIFICATION
The case manager should identify problems
oropportunitiesthatwouldbenetfromcase
management intervention.
How Demonstrated:
Documentation of agreement among
the client, family or caregiver, and other
providers and organizations regarding
theproblems/opportunitiesidentied.
Documentedidenticationofopportuni-
ties for intervention, such as:
Lack of established, evidenced-based •
planofcarewithspecicgoals
Over-utilization or under- •
utilization of services
Use of multiple providers/agencies•
Use of inappropriate services •
or level of care
Non-adherence to plan of care
•
(e.g. medication adherence)
Lack of education or understanding of:•
The disease process•
The current condition(s)•
The medication list•
Medical, psychosocial, mental health •
and/or functional limitations
Lack of a support system or presence •
of a support system under stress.
Financial barriers to adherence of the •
plan of care
Determination of patterns of care or •
behavior that may be associated with
increased severity of condition.
Compromised client safety•
Inappropriate discharge or delay from •
other levels of care
High cost injuries or illnesses•
Complications related to medical, •
psychosocial or functional issues
Frequent transitions between settings•
D. STANDARD:
PLANNING
The case manager should identify immediate,
short-term, long-term, and ongoing needs,
as well as develop appropriate and necessary
case management strategies and goals to
address those needs.
How Demonstrated:
Documentation of relevant, compre-
hensive information and data using
interviews, research, and other methods
needed to develop a plan of care.
Recognition of the client’s diagnosis,
prognosis, care needs, preferences,
preferred role in decision-making, and
outcome goals of the plan of care.
Validation that the plan of care is
consistent with evidence-based practice,
when such guidelines are available and
applicable.
16
CMSA Standards of Practice for Case Management
Establishment of measurable goals and
indicatorswithinspeciedtimeframes.
Example measures could include access
to care, cost-effectiveness of care, and
quality of care.
Documentation of client’s or client’s
support system participation in the
written case management plan of care;
documentation of agreement with plan,
including agreement with any changes or
additions.
Facilitation of problem-solving and
conictresolution.
Evidence of supplying the client with
information and resources necessary
to make informed decisions.
Awareness of maximization of client
outcomes by all available resources and
services.
Compliance with payer expectations
with respect to how often to contact and
reevaluatetheclientorredenelongor
short term goals.
E. STANDARD:
MONITORING
The case manager should employ ongoing as-
sessment and documentation to measure the
client’s response to the plan of care.
How Demonstrated:
Documentation of ongoing collaboration
with the client, family or caregiver, pro-
viders, and other pertinent stakeholders,
so that the client’s response to interven-
tions is reviewed and incorporated into
the plan of care.
Vericationthattheplanofcarecon-
tinues to be appropriate, understood,
accepted by client and support system,
and documented.
Awareness of circumstances necessitat-
ing revisions to the plan of care, such as
changes in the client’s condition, lack
of response to the care plan, preference
changes, transitions across settings, and
barriers to care and services.
Collaboration with the client, providers,
and other pertinent stakeholders regard-
ing any revisions to the plan of care.
F. STANDARD:
OUTCOMES
The case manager should maximize the cli-
ent’s health, wellness, safety, adaptation, and
self-care through quality case management,
clientsatisfaction,andcost-efciency.
How Demonstrated:
Evaluation of the extent to which the
goals documented in the plan of care
have been achieved.
Demonstrationoftheefcacy,qual-
ity, and cost-effectiveness of the case
manager’s interventions in achieving the
goals documented in the plan of care.
Measurement and reporting of the
impact of the plan of care.
Utilization of adherence guidelines,
standardized tools and proven processes.
These can be used to measure individu-
als’ preference for, and understanding of:
The proposed plans for their care•
Their willingness to change •
Their support to maintain health •
behavior change
Utilization of evidence-based guidelines
in appropriate client populations.
Evaluation of client satisfaction with case
management.
G. STANDARD:
TERMINATION OF CASE
MANAGEMENT SERVICES
The case manager should appropriately termi-
nate case management services based upon
CMSA Standards of Practice for Case Management
17
established case closure guidelines. These
guidelines may differ in various case manage-
ment practice settings.
How Demonstrated:
Identicationofreasonsforcase
management termination, such as:
Achievement of targeted outcomes •
ormaximumbenetreached
Change of health setting•
Lossorchangeinbenets(i.e.,client•
nolongermeetsprogramorbenet
eligibility requirements)
Client refuses further medical/psycho-•
social services
Client refuses further case manage-•
ment services
Determination by the case manager •
that he/she is no longer able to per-
form or provide appropriate case man-
agement services (e.g., non-adherence
of client to plan of care)
Death of the client•
Evidence of agreement of termination of
case management services by the client,
family or caregiver, payer, case manager,
and/or other appropriate parties.
Documentation of reasonable notice
of termination of case management
services that is based upon the facts and
circumstances of each individual case.
Documentation of both verbal and/
or written notice of termination of case
management services to the client and to
all treating and direct service providers.
With permission, communication of
client information to transition providers
to maximize positive outcomes.
H. STANDARD:
FACILITATION, COORDINATION,
AND COLLABORATION
The case manager should facilitate coordina-
tion, communication, and collaboration with
the client and other stakeholders in order to
achieve goals and maximize positive client
outcomes.
How Demonstrated:
Recognition of the case manager’s
professional role and practice setting in
relation to that of other providers and
organizations caring for the client.
Development and maintenance of proac-
tive, client-centered relationships and
communication with the client, and other
necessary stakeholders to maximize
outcomes.
Evidence of transitions of care, including:
A transfer to the most appropriate •
health care provider/setting
The transfer is appropriate, timely, •
and complete
Documentation of collaboration and •
communication with other health care
professionals, especially during each
transition to another level of care
within or outside of the client’s
current setting
Adherencetoclientprivacyandcon-
dentiality mandates during collaboration.
Use of mediation and negotiation to im-
prove communication and relationships.
Use of problem-solving skills and tech-
niques to reconcile potentially differing
points of view.
Evidence of collaborative efforts to op-
timize client outcomes: this may include
working with community, local and state
resources, primary care physician or
other primary provider, other members
of the health care team, the payer, and
other relevant health care stakeholders.
Evidence of collaborative efforts to
maximize regulatory adherence within
the case manager’s practice setting.
18
CMSA Standards of Practice for Case Management
I. STANDARD:
QUALIFICATIONS FOR
CASE MANAGERS
Case managers should maintain competence
in their area(s) of practice by having one of
the following:
a) Current, active, and unrestricted licensure
orcerticationinahealthorhumanservices
discipline that allows the professional to
conduct an assessment independently as
permitted within the scope of practice of the
discipline; and/or
b) Baccalaureate or graduate degree in social
work, nursing, or another health or human
serviceseldthatpromotesthephysical,
psychosocial, and/or vocational well-being of
the persons being served. The degree must be
from an institution that is fully accredited by
a nationally recognized educational accredita-
tion organization, and the individual must
havecompletedasupervisedeldexperience
in case management, health, or behavioral
health as part of the degree requirements.
How Demonstrated:
Possession of the education, experi-
ence, and expertise required for the case
manager’s area(s) of practice.
Compliance with national and/or local
laws and regulations that apply to the
jurisdictions(s) and discipline(s) in which
the case manager practice.
Maintenance of competence through
relevant and ongoing continuing
education, study, and consultation.
Practicing within the case manager’s
area(s) of expertise, making timely and
appropriate referrals to, and seeking
consultation with, others when needed.
J. STANDARD:
LEGAL
The case manager should adhere to appli-
cable local, state, and federal laws, as well
as employer policies, governing all aspects of
case management practice, including client
privacyandcondentialityrights.Itisthe
responsibility of the case manager to work
within the scope of his/her licensure.
NOTE: In the event that employer policies
orthepoliciesofotherentitiesareinconict
with applicable legal requirements, the case
manager should understand which laws
prevail. In these cases, case managers should
seekclaricationofanyquestionsorconcerns
from an appropriate and reliable expert
resource, such as an employer, government
agency, or legal counsel.
1. Standard:
Condentiality and Client Privacy
The case manager should adhere to appli-
cable local, state, and federal laws, as well as
employer policies, governing the client, client
privacy,andcondentialityrightsandactin
a manner consistent with the client’s best
interest.
How Demonstrated:
Up-to-date knowledge of, and adher-
ence to, applicable laws and regulations
concerningcondentiality,privacy,and
protection of client medical information
issues.
Evidence of a good faith effort to obtain
the client’s written acknowledgement
that he/she has received notice of privacy
rights and practices.
2. Standard:
Consent for Case Management
Services
The case manager should obtain appropri-
ate and informed client consent before case
management services are implemented.
How Demonstrated:
Evidence that the client and support
system were thoroughly informed with
CMSA Standards of Practice for Case Management
19
regard to:
Proposed case management process •
and services relating to the client’s
health conditions and needs
Possiblebenetsandcostsofsuch•
services
Alternatives to the proposed services•
Potential risks and consequences of •
the proposed services and alternatives
Client’s right to refuse the proposed •
case management services, and poten-
tial risks and consequences related to
such refusal
Evidence that the information was com-
municated in a client-sensitive manner,
which is intended to permit the client
to make voluntary and informed care
choices.
If client consent is a prerequisite to the
provision of case management services,
documentation of the informed consent.
K. STANDARD:
ETHICS
Case managers should behave and practice
ethically, adhering to the tenets of the code
of ethics that underlies his/her professional
credential (e.g., nursing, social work, rehabili-
tation counseling, etc.).
How Demonstrated:
Awarenessofthevebasicethicalprin-
ciples and how they are applied:
benecence(todogood),nonmalfea-
sance (to do no harm), autonomy (to
respect individuals’ rights to make their
own decisions), justice (to treat others
fairly),anddelity(tofollow-throughand
to keep promises).
Recognition that a case manager’s
primary obligation is to his/her clients.
Maintenance of respectful relationships
with coworkers, employers, and other
professionals.
Recognition that laws, rules, policies,
insurancebenets,andregulationsare
sometimesinconictwithethicalprin-
ciples. In such situations, case managers
areboundtoaddresssuchconictsto
the best of their abilities and/or seek
appropriate consultation.
L. STANDARD:
ADVOCACY
The case manager should advocate for the
clientattheservice-delivery,benets-adminis-
tration, and policy-making levels.
How Demonstrated:
Documentation demonstrating:
Promotion of the client’s self-
•
determination, informed and shared
decision-making, autonomy, growth,
and self-advocacy
Education of other health care and •
service providers in recognizing and
respecting the needs, strengths, and
goals of the client
Facilitating client access to necessary •
and appropriate services while educat-
ing the client and family or caregiver
about resource availability within
practice settings
Recognition, prevention, and elimina-•
tion of disparities in accessing high-
quality care and client health care
outcomes as related to race, ethnic-
ity, national origin, and migration
background; sex, sexual orientation,
and marital status; age, religion, and
political belief; physical, mental, or
cognitive disability; gender, gender
identity, or gender expression; or other
cultural factors
Advocacy for expansion or establish-•
ment of services and for client-cen-
tered changes in organizational and
governmental policy
20
CMSA Standards of Practice for Case Management
Recognition that client advocacy can
sometimesconictwithaneedto
balance cost constraints and limited
resources. Documentation indicates that
the case manager weighed decisions
with the intent to uphold client advocacy,
whenever possible.
M. STANDARD:
CULTURAL COMPETENCY
The case manager should be aware of, and re-
sponsive to, cultural and demographic diversity
ofthepopulationandspecicclientproles.
How Demonstrated:
Documentation demonstrating:
Case manager understands relevant •
cultural information and communi-
cates effectively, respectfully, and
sensitively within the client’s cultural
context
Assessment of client linguistic needs •
and identifying resources to enhance
proper communication. This may in-
clude use of interpreters and material
in different languages and formats,
as necessary, and understanding of
cultural communication patterns of
speech volume, context, tone, kinetics,
space, and other similar verbal/non-
verbal communication patterns
Evidence of pursuit of education in
cultural competence to enhance the case
manager’s effectiveness in working with
multicultural populations.
N. STANDARD:
RESOURCE MANAGEMENT
AND STEWARDSHIP
The case manager should integrate factors
related to quality, safety, access, and cost-
effectiveness in assessing, monitoring, and
evaluating resources for the client’s care.
How Demonstrated:
Documentation of evaluating safety,
effectiveness, cost, and potential
outcomes when designing care plans to
promote the ongoing care needs of the
client.
Evidence of follow-through on care plan
objectives, including assisting with refer-
ral and outsourcing as needed, based on
the ongoing care needs of the client and
the competency, knowledge, and skill of
the health and human services providers.
Evidence of utilizing evidence-based
guidelines, as available, and guidelines
specictothecasemanager’sprac-
tice setting in making decisions about
resource allocation and utilization.
Demonstration of linking the client
and family or caregiver with resources
appropriate to the needs and goals iden-
tiedinthecareplan.Fullyinforming
the client and family or caregiver of the
length of time for which each resource
isavailable,theirnancialresponsibility
for each resource, and the anticipated
outcome of resource utilization.
Documented communication of the
client and other providers, both internal
and external, especially during care
transitionsorwhenthereisasignicant
change in the client’s situation.
Evidence of promoting the most effective
andefcientuseofhealthcareservices
andnancialresources.
Documentation demonstrating that the
intensity of case management services
rendered corresponds with the needs of
the client.
CMSA Standards of Practice for Case Management
21
O. STANDARD:
RESEARCH AND RESEARCH
UTILIZATION
The case manager should maintain familiar-
itywithcurrentresearchndingsandbe
able to apply them, as appropriate, in his/her
practice.
How Demonstrated:
Evidence of familiarization with current
literature pertaining to the case manag-
er’s expertise, and regular participation
in appropriate training and/or confer-
ences to maintain knowledge and skills.
Compliance with legitimate and relevant
research efforts, in order to quantify and
denevalidandreliableoutcomesin
case management.
Incorporation of meaningful research
ndingsintopracticeasappropriate.
Participationinidentication
of practical, hands-on approaches to
case management “best practices.”
22
CMSA Standards of Practice for Case Management
IX. Acknowledgements
CMSA would like to extend our gratitude
to all of the Professionals who graciously
gave their time and expertise to revise
and comment on the
Case Management
Standards of Practice
(2010).
We would especially like to thank
those in the various Standards of Practice
Workgroups:
Committee Chair: Carrie Marion, RN, BSN, CCM
Executive Director, CMSA: Cheri Lattimer, RN,
BSN
Staff Liaison: Danielle Marshall
Medical Writer: Suzanne K. Powell, RN, BSN, MBA,
CCM, CPHQ
Task Force Members:
Margaret Chu, RN, BSN, MPA, RNC, CCM, CPHQ•
Connie Commander, RN-BC, BS, CCM, ABDA, CPUR•
Bill Downey, PhD, CRC•
Michael B. Garrett, MS, CCM, CVE, NCP, RMHC•
Chris Herman, MSW, LICSW, LCSW-C•
Diane L. Huber, PhD, RN, FAAN, NEA-BC•
Mary Beth Newman, RN-BC, MSN, A-CCC, CMAC, •
CCP, MEP
Nancy Skinner, RN-BC, CCM•
Debbie Stubbs, RN, MS, CCM•
Karyn Walsh, ACSW, LCSW•
Annette Watson, RN-BC, CCM, MBA•
Reference Group Members:
Nancy Benoit, RN CRRN, CCM•
Sue Binder, RN-BC, CCM, PAHM•
Joan Bowman, RN, BSN, MPA, CCM•
Sharon Brim, RN, BSN, CCM•
Lisa Cantrell, RN, BA, CCM•
Toni Cesta, PhD, RN, FAAN•
Mary Chase, RN, CCM•
Stefani Daniels, RN, MSNA, ACM, CMAC•
Maureen J. Fiore, RN, CCM•
Ann Flaherty-Quemere, RN•
Denise Gard, RN-BC, BSN, CCM•
Kathy Gremel, RN, MS•
RuthAnn Harp, RN, CCM•
Doris Imperati, BSN, MHSA, CCM•
Patricia Kiley, ARNP, CCM, LNC•
Karen Kraemer, RN, CMC•
Sandra Lowery, RN, CRRN, CCM, CNLCP•
Mary Jane McKendry, RN, MBA, CCM, CHE•
Susan M. Orlando, RN, BSN, CCM•
Linda Ownbey, RN, BSN, CCM, CHRM, COS•
Diane J. Powell, RN/ANP, MBA, CCM•
Pauline Rainey, RGN, NZRN Comp, •
PGDIP Health Management
Linda Raney, MSN, CPUM, CPUR•
Bonnie Robb, RN, BSN, CCM, CNLCP•
Susan Rogers, RN-BC, BSN, CCM•
Kim Schuetze, ACSW, CCM•
Marcia D. Stewart, RN, MHA, CAN•
Kimberly Such-Smith, BSN, RN, LNC, CMC•
Connie Sunderhaus, RN, CCM•
Marilyn Van Houten, RN, MS, CDMS, CCM•
Jon P. Veltri MEd, CAS, CRC, CCM, CDMS, CPDM, •
CEAS
Kim Woll-Hulsey, RN, CCM •
Advisory Group Members:
Peter Moran, MS, BSN, RN-BC, CCM•
Kathleen Moreo, RN-BC, Cm, BSN, BHSA, CCM, •
CDMS
Lynn S. Muller, RN, BA, CCM, JD, JMC•
Hussein A. Tahan, DNSc, RN•
John Blakney, BSN, MSN•
CMSA Standards of Practice for Case Management
23
X. Glossary
Activity: A discrete action or task a person
performs to meet the expectations of the role
assumed. For example, an acute care case
manager “completes concurrent reviews” with
a payer-based case manager.
Advocacy: The act of recommending, plead-
ing the cause of another; to speak or write in
favor of.
Assessment: A systematic process of data
collection and analysis involving multiple ele-
ments and sources.
Care Coordination: The deliberate organi-
zation of patient care activities between two
or more participants (including the patient)
involved in a patient’s care to facilitate the
appropriate delivery of health care services.
Organizing care involves the marshalling of
personnel and other resources needed to carry
out all required patient care activities, and is
often managed by the exchange of informa-
tion among participants responsible for differ-
ent aspects of care (AHRQ, 2007).
Care Management: A health care deliv-
ery process that helps achieve better health
outcomes by anticipating and linking clients
with the services they need more quickly. Case
management may help to avoid unnecessary
services by reducing medical complications
(CCMC, 2009). This term often refers to the
management of long-term health care, legal,
andnancialservicesbyprofessionalsserving
socialwelfare,agingandnonprotcarede-
livery systems. Services are delivered under a
psychological model (Powell & Tahan, 2008).
Case Management: A collaborative process
of assessment, planning, facilitation, care
coordination, evaluation, and advocacy for
options and services to facilitate an indi-
vidual’s and family’s comprehensive health
needs through communication and available
resources to promote quality cost-effective
outcomes (CMSA, 2010).
Case Management Plan of Care:
A comprehensive plan that includes a state-
ment of problems/needs determined upon as-
sessment; strategies to address the problems/
needs; and measurable goals to demonstrate
resolution based upon the problem/need, the
time frame, the resources available, and the
desires/motivation of the client.
Case Management Process: The man-
ner in which case management functions are
performed, including: assessment, problem
identication,outcomeidentication,plan-
ning, monitoring, and evaluating.
Certication: A process by which a
government or non-government agency
grants recognition to those who have met
predeterminedqualicationsassetforthbya
credentialing body.
Client: (1) Individual who is the recipient of
case management services. This individual
canbeapatient,beneciary,injuredworker,
claimant, enrollee, member, college student,
resident, or health care consumer of any age
group. In addition, when
client
is used, it may
also infer the inclusion of the client’s support.
(2) Client can also imply the business relation-
ship with a company who contracts for or
paysforcasemanagementservices.Therst
denitionistheoneusedthroughoutthe
Standards of Practice
2010.
Client Support System: The client’s sup-
portsystemisdenedbyeachclientandmay
include biological relatives, spouses, partners,
friends, neighbors, colleagues, or any indi-
vidual who supports the client.
24
CMSA Standards of Practice for Case Management
Consumer: An individual person who is the
direct or indirect recipient of the services of
the organization. Depending on the context,
consumersmaybeidentiedbydifferent
names,suchas“member,”“enrollee,”“bene-
ciary,” “patient,” “injured worker,” “claimant,”
etc. A consumer relationship may exist even in
cases where there is not a direct relationship
between the consumer and the organization.
For example, if an individual is a member of
a health plan that relies on the services of a
utilization management organization, then
the individual is a consumer of the utilization
management organization.
Cultural Competence: The process by
which individuals and systems respond
respectfully and effectively to people of all
cultures, languages, classes, races, ethnic
backgrounds, religions, and other diversity
factorsinamannerthatrecognizes,afrms,
and values the worth of individuals, families,
and communities and protects and preserves
the dignity of each (NASW, 2007).
Culture: The integrated pattern of human
behavior that includes thoughts, communica-
tions, actions, customs, beliefs, values, and
institutions of a racial, ethnic, religious, or
social group. Culture may include, but is not
limited to, race, ethnicity, national origin, and
migration background; sex, sexual orientation,
and marital status; age, religion, and political
belief; physical, mental, or cognitive disability;
gender, gender identity, or gender expression
(Cross, Bazron, Dennis, & Isaacs, as cited in
U.S. Department of Health and Human Ser-
vices,OfceofMinorityHealth,2001).
Disease Management: Disease man-
agement is a system of coordinated health
care interventions and communications for
populations with conditions in which patient
self-careeffortsaresignicant.Becauseofthe
presence of co-morbidities or multiple condi-
tions in most high-risk patients, this approach
maybecomeoperationallydifculttoexecute,
with patients being cared for by more than
one program. Over time, the industry has
moved more toward a whole person model
in which all the diseases a patient has are
managed by a single disease management
program(DMAAdenition).
Evidence-Based Criteria: Guidelines for
clinical practice that incorporate current and
validatedresearchndings.
Family: Family members and/or those indi-
viduals designated by the client as the client’s
support system.
Function: Agroupingofasetofspecic
tasks within the role. The set of tasks that
constitutes one function tends to focus on a
common theme and share the same goal; for
example, “evaluation of outcomes” or “coor-
dination of treatments.”
Health:Inadditiontothefourdenitions
of “health” listed below, case management’s
denitionofhealthtakesonamorecompre-
hensive meaning that includes biopsychoso-
cial, as well as educational and vocational,
aspects of the client:
1. Health is a state of complete physical,
mental and social well-being and not
merelytheabsenceofdiseaseorinrmity
(WHO Constitution).
2. The extent to which an individual or a
group is able to realize aspirations and
satisfy needs, and to change or cope
with the environment. Health is a re-
source for everyday life, not the objective
of living; it is a positive concept, em-
phasizing social and personal resources
as well as physical capabilities (Health
Promotion: A Discussion Document,
Copenhagen: WHO 1984).
3. A state characterized by anatomic, physi-
ologic and psychological integrity; ability
to perform personally valued family, work
and community roles; ability to deal with
physical, biologic, psychological and
CMSA Standards of Practice for Case Management
25
social stress; a feeling of well-being; and
freedom from the risk of disease and
untimelydeath(J.Stokesetal.“Deni-
tion of terms and concepts applicable to
clinical preventive medicine,” J Common
Health, 1982; 8:33-41).
4. A state of equilibrium between humans
and the physical, biologic and social
environment, compatible with full func-
tional activity (JM. Last, Public Health
and Human Ecology, 2nd ed. Stamford,
CT: Appleton and Lange, 1997).
Health Outcomes: Changes in current or
future health status of individuals or com-
munities that can be attributed to antecedent
actions or measures (EURO European Centre
for Health Policy, ECHP, Brussels, 1999).
Health Services: Medical services and/or
health and human services.
Kinetics: A communication pattern referring
to the use of stance, gestures, eye behavior
and other posturing by an individual in non-
verbal communication.
Licensure: Licensure is a process by which a
government agency grants permission to an
individual to engage in a given occupation,
provided that person possesses the minimum
degree of competency required to reasonably
protect public health, safety, and welfare.
Managed Care: Services or strategies
designed to improve access to care, quality
of care, and the cost-effective use of health
resources. Managed care services include,
but are not limited to, case management,
utilization management, peer review, disease
management, and population health.
Medical Home: A medical home model pro-
vides accessible, continuous, coordinated and
comprehensive patient-centered care, and is
managed centrally by a primary care physician
with the active involvement of non-physician
practice staff. Providers deemed a medical
home may receive supplemental payments
to support operations expected of a medical
home. Physician practices may be encouraged
or required to improve practice infrastructure
andmeetcertainqualicationsinorderto
achieve eligibility.
Outcomes: Measurable results of case
management interventions, such as client
knowledge, adherence, self-care, satisfaction,
and attainment of a meaningful lifestyle.
Payer: An individual or entity that funds
related services, income, and/or products for
an individual with health needs.
Predictive Modeling: Modeling is the
process of mapping relationships among
data elements that have a common thread.
Through predictive modeling, data is “mined”
with software to examine and recognize pat-
terns and trends, which can then potentially
forecast clinical and cost outcomes. This al-
lows an organization to make better decisions
regarding current/future staff and equipment
expenditures, provider and client education
needs,allocationofnances,aswellasto
better risk stratify population groups.
Provider: The individual, service organiza-
tion, or vendor who provides health care
services to the client.
Risk Stratication: The process of catego-
rizing individuals and populations according
to their likelihood of experiencing adverse
outcomes, e.g., high risk for hospitalization.
Role: A general and abstract term that
refers to a set of behaviors and expected
consequences that are associated with one’s
position in a social structure. Usually, organi-
zations and employers use a person’s title as a
proxy for his/her role; for example, “acute care
case manager.”
Space: A communication pattern referring to
the physical distance or “comfort proximity”
selected by an individual when communicat-
ing with another individual.
26
CMSA Standards of Practice for Case Management
Speech Context: A communication pattern
referring to the use/non-use of emotion by an
individual in verbal communication.
Speech Volume: A communication pattern
referring to the level of loudness or softness
used by an individual in verbal communica-
tion.
Standard: An authoritative statement agreed
to and promulgated by the practice by which
the quality of practice and service can be
judged.
Stewardship: Responsibleandscally
thoughtful management of resources.
Transitional Care: Transitional care includes
all the services required to facilitate the
coordination and continuity of health care as
the patient moves between one health care
service provider to another.
Transitions of Care: Transitions of care is
the movement of patients from one health
care practitioner or setting to another as their
condition and care needs change. Also known
as “care transitions.”
References
AHRQ, 2007.
Closing the Quality Gap:
A critical analysis of quality improvement
strategies.
Publication No. 04(07)-0051-
7, Volume 7 - Care Coordination,
June 2007.
Case Management Society of America,
(1995).
Standards of Practice for Case
Management.
Little Rock, Arkansas.
Case Management Society of America,
(revised, 2002).
Standards of Practice for
Case Management.
Little Rock, Arkansas.
Case Management Society of America,
2009. (CMSA)
Mission and Vision
. Ac-
cessed from the World Wide Web on July
7, 2009 at http://www.cmsa.org/Home/
CMSA/OurMissionVision/tabid/226/De-
fault.aspx
National Association of Social Work-
ers (NASW). (2007).
Indicators for the
achievement of the NASW standards
for cultural competence in social work
practice
. Washington, DC: NASW Press.
National Association of Social Workers
(NASW). (2009). Cultural and linguistic
competence in the social work profes-
sion.
Social work speaks: National
Association of Social Workers policy
statements
, 2009-2012 (8th ed., pp.
70-76). Washington, DC: NASW Press.
Powell, S.K. & Tahan, H.A. (2008). Case
Management Society of America (CMSA)
Core Curriculum for Case Management
,
(Ed. 2). Philadelphia: Lippincott Williams
& Wilkins.
U.S. Department of Health and Human
Services,OfceofMinorityHealth.
(2001).
National standards for culturally
and linguistically appropriate services in
health care
. Final report. Retrieved June
29, 2009, from http://www.omhrc.gov/
assets/pdf/checked/nalreport.pdf
Case Management Society of America
6301 Ranch Drive
Little Rock, Arkansas 72223
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E [email protected]
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The Standards of Practice for Case Management,
Revised 2010 ©Copyright 2010 Case Management
Society of America, Little Rock, Arkansas, USA.
All rights reserved under both international and
Pan-American copyright conventions. No reproduction
of any part of this material may be made without the
prior written consent of the copyright holder.
CMSA Standards of Practice for Case Management
27
6301 Ranch Drive l Little Rock, Arkansas 72223
T 501.225.2229 l F 501.227.5444 l E [email protected]g
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