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II. Evolution of the Standardsof Practice for Case ManagementA. Standards of Practicefor Case Management (1995)the collaborative, ethical, and legal sections(CMSA, 1995).In 1995, the President of the CMSA wrotea foreword in the 1995 CMSA Standards ofPractice. In it he stated that the “developmentof national Standards represents a major stepforward for case managers. The future of ourpractice lies in the quality of our performance,as well as our outcomes” (CMSA, 1995, pg.3).These first Standards included this definitionof case management (CMSA, 1995, pg.8):Case management is a collaborative process which assesses, plans,implements, coordinates, monitors andevaluates options and services to meetan individual’s health needs throughcommunication and available resources to promote quality cost-effectiveoutcomes.The 1995 Standards of Practice wererecognized as an anticipated tool that casemanagement would utilize within every casemanagement practice arena. They wereseen as a guide to move case managementpractice to excellence. The Standards exploredthe planning, monitoring, evaluating andoutcomes phases, followed by PerformanceStandards for the practicing case manager.The Performance Standards addressed howthe case manager worked within each of theestablished Standards and with other disciplines to follow all legal requirements.Even at this first juncture, the Standardscommittee recognized the importance ofthe case managers basing their individualpractice on valid research findings and theyencouraged case managers to participate inthe research process, programs, and development of specific tools for the practice of casemanagement. This was evidenced by key sections that highlighted measurement criteria inB. Standards of Practicefor Case Management (2002)6CMSA Standards of Practice for Case ManagementThe 2001 Board of Directors for CMSAidentified the need for a careful and thoroughreview and, if appropriate, revision of theinitial published Standards. The revised Standards of Practice for Case Management werepublished in 2002. The published definition ofcase management was amended to (CMSA,2002, pg. 5):Case management is a collaborative process of assessment, planning,facilitation and advocacy for optionsand services to meet an individual’shealth needs through communicationand available resources to promotequality cost-effective outcomes.The section on Performance Indicatorswas expanded to further define the casemanager. The purpose of case managementwas revised to address quality, safety andcost-effective care, as well as to focus uponfacilitating appropriate access to care.Primary case management functions in2002 included both current and new skillsand concepts: positive relationship-building;effective written/verbal communication; negotiation skills; knowledge of contractual andrisk arrangements, the importance of obtaining consent, confidentiality, and client privacy;attention to cultural competency; ability toeffect change and perform ongoing evaluation; use of critical thinking and analysis; ability to plan and organize effectively; promoteclient autonomy and self-determination; andknowledge of funding sources, health careservices, human behavior dynamics, healthcare delivery and financing systems, and clinical standards and outcomes.

Improving outcomes by utilizing adherence guidelines, standardized tools, andproven processes to measure a client’sunderstanding and acceptance of theproposed plans, his/her willingness tochange, and his/her support to maintainhealth behavior change. The Standards of Practice for Case Management 2010 include topics that influence thepractice of case management in the currenthealth care environment. Included in thisrevision are:Expanding the interdisciplinary team toinclude clients and/or their identifiedsupport system, health care providers,including community-based and facilitybased professionals (i.e., pharmacists,nurse practitioners, holistic care providers, etc.). Expanding the case management role tocollaborate within one’s practice settingto support regulatory adherence. Addressing the total individual, inclusiveof medical, psychosocial, behavioral, andspiritual needs. Moving clients to optimal levels of healthand well-being. Improving client safety and satisfaction. Collaborating efforts that focus uponmoving the individual to self-care whenever possible. Improving medication reconciliation for aclient through collaborative efforts withmedical staff. Increasing involvement of the individualand caregiver in the decision-makingprocess. Improving adherence to the plan ofcare for the client, including medicationadherence. Minimizing fragmentation of care withinthe health care delivery system.Case management work applied to individual clients or to groups of clients, such asin disease management or population healthmodels. The facilitation section included moredetail about the importance of communication and collaboration on behalf of the clientand the payer. The practice settings for casemanagement were increased to capture theevolution of, and the increase in, the numberof venues in which case managers worked.C. Standards of Practice forCase Management (2010) Using evidence-based guidelines, asavailable, in the daily practice of casemanagement. Focusing on transitions of care, whichincludes a complete transfer to the nextcare setting provider that is effective,safe, timely, and complete.These changes advance case management credibility and complement the currenttrends and changes in health care. Futurecase management Standards of Practice willlikely reflect the existing climate of health careand build upon the evidence-based guidelinesthat are proven successful in the coming years.CMSA Standards of Practice for Case Management7

III. Definition of Case ManagementThe basic concept of case managementinvolves the timely coordination of qualityservices to address a client’s specific needsin a cost-effective manner in order to promotepositive outcomes. This can occur in a singlehealth care setting or during the client’s transitions of care throughout the care continuum.The case manager serves as an importantfacilitator among the client, family or caregiver, the health team, the payer, and thecommunity.As demonstrated in the section on theEvolution of the Standards of Case Management, the definition of case managementhas evolved over a period of time; it reflectsthe vibrant and dynamic progression of thestandards of practice.Following more than a year of study anddiscussion with members of the National CaseManagement Task Force, the CMSA’s Boardof Directors approved a definition of casemanagement in 1993.8CMSA Standards of Practice for Case ManagementSince that time, the CMSA Board of Directors has repeatedly reviewed and analyzedthe definition of case management to ensureits continued application in a dynamic healthenvironment. The definition was modified in2002 to reflect the process of case management outlined within the Standards. Thedefinition was again revisited in 2009 andmodified to further align with the currentpractice of case management.While there are many definitions of casemanagement, the 2009 definition approvedby CMSA is as follows (CMSA, 2009):Case management is a collaborative process of assessment, planning,facilitation, care coordination, evaluation, and advocacy for options andservices to meet an individual’s andfamily’s comprehensive health needsthrough communication and availableresources to promote quality costeffective outcomes.

IV. Philosophy and Guiding PrinciplesA. Statement of PhilosophyA philosophy is a statement of belief that setsforth principles to guide a program and theindividual in his/her practice of that program(Powell & Tahan, 2008). The CMSA’s philosophy of case management statement articulates that (CMSA, 2009):The underlying premise of casemanagement is based in the fact that,when an individual reaches the optimum level of wellness and functionalcapability, everyone benefits: theindividuals being served, their supportsystems, the health care delivery systems and the various reimbursementsources. Case management serves asa means for achieving client wellnessand autonomy through advocacy,communication, education, identification of service resources and servicefacilitation. . Case managementservices are best offered in a climatethat allows direct communicationbetween the case manager, the client,and appropriate service personnel, inorder to optimize the outcome for allconcerned.The philosophy of case managementunderscores the recommendation that individuals, particularly those experiencing catastrophic injuries or severely chronic illnesses,be evaluated for case management services.The key philosophical components of casemanagement address care that is holistic andclient-centered, with mutual goals, allowingstewardship of resources for the client andthe health care system. Through these efforts,case management focuses simultaneously onachieving health and maintaining wellness tothe highest level possible for each client.It is the philosophy of case management that when health care is appropriatelyand efficiently provided, all parties benefit.The provision of case management, workingcollaboratively with the health care team incomplex situations, serves to identify careoptions which are acceptable to the client.This will, in turn, increase adherence to theplan of care and successful outcomes. Casemanagement reduces the fragmentation ofcare, which is too often experienced by clientswho obtain health care services from multipleproviders. Taken collectively, services offeredby a case manager can enhance a client’ssafety, well-being and quality of life, whilereducing total health care costs. Thus, effective case management can directly and positively affect the health care delivery system.B. Guiding PrinciplesGuiding principles are relevant and meaningful concepts that clarify or guide practice.Guiding principles for case management practice include the following. Case managers: Use a client-centric, collaborativepartnership approach. Whenever possible, facilitate selfdetermination and self-care throughthe tenets of advocacy, shared decisionmaking, and education. Use a comprehensive, holistic approach. Practice cultural competence, withawareness and respect for diversity. Promote the use of evidence-based care,as available. Promote optimal client safety. Promote the integration of behavioralchange science and principles.CMSA Standards of Practice for Case Management9

10Link with community resources.Case management guiding principles,interventions,and strategies are targeted atAssist with navigating the health caretheachievementof client stability, wellness,system to achieve successful care, forandautonomythroughadvocacy, assessment,example during transitions.planning, communication, education, resourcePursue professional excellence and main- management, care coordination, collaboratain competence in practice.tion, and service facilitation.They are based on the needs andPromote quality outcomes and measurevaluesof the client and are accomplishedment of those outcomes.in collaboration with all service providers.Support and maintain compliance withfederal, state, local, organizational, and This accomplishes care that is appropriate,effective, client-centered, timely, efficient, andcertification rules and regulations.equitable.CMSA Standards of Practice for Case Management

V. Case Management Practice SettingsCase management practice extends across all health care settings, including payer, provider, government, employer, community, and homeenvironment. However, the practice varies indegrees of complexity and comprehensiveness based on the following four factors (Powelland Tahan, 2008):1.The context of the care setting, suchas wellness and prevention, acute, orrehabilitative.2.The health conditions and needs of thepatient population(s) served, as well asthe needs of the family/caregivers, suchas critical care, asthma, renal failure,hospice care.3.4.The following is a representative list ofcase management practice settings; however,it is not an exhaustive list of settings wherecase managers exist. Case managers work in: Hospitals and integrated care deliverysystems, including acute care, subacute care, long-term acute care (LTAC)facilities, skilled nursing facilities (SNF),rehabilitation facilities. Public health insurance programs, e.g.,Medicare, Medicaid, state-funded programs.Private health insurance programs,e.g., workers’ compensation, occupational health, disability, liability, casualty,automotive, accident and health, longterm care insurance, group healthinsurance, managed care organizations. Independent and private case management companies. Government-sponsored programs,e.g., correctional facilities, militaryhealth care/Veterans Administration,public health.The reimbursement method applied, such as managed care, workers’ compensation, Medicare, or Medicaid.The health care professional disciplinedesignated as the case manager, such asregistered nurse, social worker, physician, rehabilitation counselor, etc.Corporations.Provider agencies and community facilities, i.e., mental health facilities, homehealth services, ambulatory and day carefacilities. Geriatric services, including residentialand assisted living facilities. Long-term care services, including homeand community based services. Hospice, palliative, and respite careprograms. Physician and medical group practices. Life care planning programs. Disease management companies.Ambulatory care clinics and communitybased organizations, including student/university counseling and health carecenters.CMSA Standards of Practice for Case Management11

VI. Case Management Roles, Functions,and ActivitiesIt is necessary to differentiate between theterms “role,” “function,” and “activity,” beforedescribing what case managers do. Definingthese terms is essential to providing a clearand contextual understanding of the roles andresponsibilities of case managers.A role is a general and abstract termthat refers to a set of behaviors and expectedconsequences that are associated with one’sposition in a social structure. A function is agrouping of a set of specific tasks within therole. An activity is a discrete action or task aperson performs to address the expectationsof the role assumed (See Glossary).A role tends to consist of several functions and each function is described througha list of specific activities. These descriptionsconstitute what is known as a “job description.” The roles assumed by case managersvary based on the same four factors describedin the section entitled, Case ManagementPractice Setting.The case manager performs the primaryfunctions of assessment, planning, facilitationand advocacy, which are achieved throughcollaboration with the client and other healthcare professionals involved in the client’scare. Key responsibilities of case managementhave been identified by nationally recognizedprofessional societies and certifying bodiesthrough case management roles and functionsresearch.It is not the intent of the Standardsto parallel these key responsibilities; theStandards will broadly define major functionsinvolved in the case management process toachieve desired outcomes.Successful outcomes cannot be achievedwithout specialized skills and knowledgeapplied throughout the process. These skillsinclude, but are not limited to, positive rela12CMSA Standards of Practice for Case Managementtionship-building; effective written and verbalcommunication; negotiation; knowledge ofcontractual or risk arrangements; the abilityto effect change, perform ongoing evaluationand critical analysis; and the ability to planand organize effectively.It is important for the case manager tohave knowledge of funding sources, healthcare services, human behavior dynamics, thehealth care delivery and financing systems,and clinical standards and outcomes. Theskills and knowledge base of a case managermay be applied to individual clients, or togroups of clients, such as in disease management or population health models.Role functions of case managers include: Conducting a comprehensive assessmentof the client’s health and psychosocialneeds, including health literacy statusand deficits, and develops a case management plan collaboratively with theclient and family or caregiver. Planning with the client, family orcaregiver, the primary care physician/provider, other health care providers, thepayer, and the community, to maximizehealth care responses, quality, and costeffective outcomes. Facilitating communication and coordination between members of the healthcare team, involving the client in thedecision-making process in order tominimize fragmentation in the services. Educating the client, the family or caregiver, and members of the health caredelivery team about treatment options,community resources, insurance benefits,psychosocial concerns, case management, etc., so that timely and informeddecisions can be made.

Empowering the client to problem-solveby exploring options of care, whenavailable, and alternative plans, whennecessary, to achieve desired outcomes. Encouraging the appropriate useof health care services and strivesto improve quality of care andmaintain cost effectiveness ona case-by-case basis. Assisting the client in the safetransitioning of care to the nextmost appropriate level. Striving to promote client self-advocacyand self-determination. Advocating for both the client and thepayer to facilitate positive outcomes forthe client, the health care team, and thepayer. However, if a confl

CMSA Standards of Practice for Case Management 3 Preface T he Standards of Practice for Case Management were first introduced by the CMSA in 1995 and then revised in 2002. we are pleased to offer the Standards of Practice for