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Running Head: ROLE OF COMMUNITY CASE MANAGER

Role of Community Case Manager

Elizabeth Ping - T-012

Gladeen Roberts

Spring Arbor University

March 2, 2010
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Running Head: ROLE OF COMMUNITY CASE MANAGER

Role of Community Case Manager

American healthcare today places great importance on providing high quality of care

while keeping cost at a minimum. In recent years, the many biopsychosocial needs of the

growing elderly population and the increasing state of disjointed and complicated healthcare has

promulgated the need for community-based case managers to take a more central role in

directing patient’s individual needs. Particularly, community case managers act to fill the gap

between the discrepancies in knowledge that healthcare providers and patients have about access

to care by educating and referring patients to the best financially eligible and appropriate

programs for their multisystem diseases as possible. Through case management, the uninformed

patient and uncoordinated healthcare provider can come together to construct effective treatment

plans that produce better patient outcomes and increase the effectiveness of limited resources.

The following will discuss the role of the community case manager in terms of specialties and

desired characteristics, the challenges faced by community case managers, and nurse

management theory applied to the community setting.

Role

Case managers act as coordinators and liaisons between the delivery of patient services

and the patients who desire services in order to achieve patient wellness and autonomy.

Specifically, the Case Management Society of America (2010) defines case management as, “a

collaborative process of assessment, planning, facilitation, and advocacy for options and services

to meet an individual’s health needs through communication of available resources to promote

quality cost-effective outcomes.” However, the role of case management varies depending on the

environment and needs of patients and payers. While some case managers work strictly in the

hospital setting and only advocate for patients while they are within their system, others choose
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Running Head: ROLE OF COMMUNITY CASE MANAGER

the role of direct-to-consumer case managers in the community in order to promote community

residency of patients with complex health conditions.

According to Klemzack, Bowman, and Wehrein, community case managers coordinate a

patient’s care beyond hospitalizations to provide a continuum of care comfortably at home,

ensure and facilitate quality of clinical and financial outcomes for community services, negotiate

and procure community services and resources for patients and families, intervene and resolve

problems in the care of the patient when deviations of quality occur, and continually create

opportunities to enhance the outcomes of patients through (as cited by Pieroni, n. d., p. 2).

Additionally, Yamamoto and Lucey (2005), highlight another aspect of community nurse care

which includes being an educator to patients, family members, and other healthcare providers

(pp. 171-72). They assert that positive patient outcomes can be better met when appropriate

teaching methods, in context with individual cultural beliefs, address deficiencies in a patient’s

knowledge about disease processes, treatment, insurance coverage, deductibles, co-pays, and

available community resources. According to Neff (2009), education plays an ever-increasing

role in community case management as more patients present with memory loss and disorders

that affect their short-term memories such as dementia (p. 89).

It can be helpful to view how an actual nurse case manager directs care in the community

setting in order to better understand the multifaceted roles direct-to-consumers take on. Neff

(2009) describes her typical duties as community case manager for the 36 indigent and medically

frail patients in her community, who are referred to her after hospital stays (pp. 88-90). She

explains that many of her job duties involve more than the coordination care for her patients, and

Neff asserts that she plays a central role in helping her patients live in safety at home. Neff

facilitates safe nursing by basing care on findings from conducting physical assessments that
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Running Head: ROLE OF COMMUNITY CASE MANAGER

address the entire body, continually educating patients and families, conducting medication

reconciliations to assess for issues such as poly-pharmacy, setting up medications in pill boxes

for patients, and making doctor’s appointments for patients who are unable to physically use the

telephone.

Targeted Specialties. There are many vulnerable populations that community case

managers can increase effectiveness and efficiency of healthcare resources. Bowman, Klemzack

and Wehrein (n. d.), describe that the typical patient types that the community case manager

visits are those who have two or more chronic diseases and who are seen by three or more

healthcare providers (p. 3). Chronic conditions that are targeted in the community setting include

those patients who have technological dependencies, diabetes, children with special needs and

medical problems, heart disease, hypertension, obesity, renal insufficiency, chronic obstructive

disease, arthritis, anxiety, depression, bipolar, disorder, schizophrenia, dementia, cancer, HIV,

AIDS, and those in need of pain management (Bowman, Klemzack & Wehrein, n. d,; Mullahy,

2010; Neff, 2009; Poo, Hendricks, Cheng, & Mahendran, 2009). Other populations also benefit

from the services that are provided by community case managers and include children at or

below the poverty level, Medicaid and Medicare patients, high-risk maternity patients, and

working adults who are uninsured, and those who need hospice or palliative care (Bowman,

Klemzach & Wehrein, n. d.; Mullahy, 2010).

Characteristics. Education, credentialing, and experience play vital roles in the necessary

characteristics of a well-qualified case manager. Although historically, case management was

mainly a role that was trained for in the hospital setting, White and Hall (2006) explain that

education for nurse case managers has since been integrated into the academic setting and that

education at the Baccalaureate level should be the minimum with graduate preparation the
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Running Head: ROLE OF COMMUNITY CASE MANAGER

desired preference (p. 4). Furthermore, White and Hall explain the importance of certification by

exam is another desired characteristics for case managers today so that the case manager’s broad

knowledge of the healthcare system can be substantiated.

Whereas the expectations for education and credentialing are more limited, the desired

experience for a role in community case management can take a variety of forms. Mullahy

(2010), describes that case managers often come from such diversified backgrounds as business,

home health care, occupational health, clinics, medical-surgical units, intensive care, psychology,

obstetrics, pediatrics, and neurological units (pp. 10-11). Regardless of education, certification,

and prior experience, community case managers should possess a variety of traits which include

but are not exhaustive to those found in Table One.

Desired Characteristics of the Community Case Manager

Commitment and desire to work in case Proactive mindset
management
Good management skills Adaptability and flexibility
Team player Creativity
Good insurance knowledge base Computer skills
Good communication skills telephonically and Prioritizing skills
in person
Ability to read poor penmanship Organization skills
Confidence and self esteem Negotiation skills
Caring attitude Assertiveness
Diplomatic Sense of humor
Resourceful Autonomous
Disciplined Accountable
Willingness to act as change agent Good knowledge of community resources
Patient advocacy Strong ethics and values
Educator Good coordinator and facilitator
Good legal Good Assessment skills
Table One. Desired Characteristics of the Community Case Manager. (Mullahy, 2010, White &

Hall, 2006; Yamamoto & Lucey, 2005)

Challenges
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Running Head: ROLE OF COMMUNITY CASE MANAGER

Community case managers face a variety of challenges as they strive to improve quality

of care while keeping the cost of service at a minimum. Effective case managers utilize their

positive attributes to empower themselves and their patients to overcome challenges and provide

the greatest access to particular healthcare needs. Resistance in payers and patients to follow or

agree to ongoing care, inability to negotiate the plan of care, the individual ethics of the case

manager, the role of the case manager as a change agent, and restrictions in the case manager’s

ability to provide opportunities are just some of the problems faced by community-based case

managers who are attempting to coordinate, facilitate, and catalyze the care of patients.

Resistance. Nurse case managers face resistance from the people that they are trying to

provide quality care to and the payers of healthcare services who approve for treatment. The

inability of patients to adhere to a plan of care can be seen in most areas of community care.

Bowman, Klemzack, and Wehrein report that the annual cost to the national economy is 100

billion dollars when medications are not taken correctly (as cited by Moreo, n. d. p. 2). The

psychiatric population presents a similar challenge to case managers presenting treatment plans

to patients in the community who must be repeatedly reminded why taken medications are

important to their overall health. Noncompliance can also be seen when diabetic patients refuse

to follow the dietary guidelines set by their physicians and when patients continue to smoke or

abuse alcohol despite continual counseling.

Resistance in payers to provide longer length of stays, extend coverage caps beyond their

initial limits, and refusal to approve different types of care facilities is another area of difficulty

for the practicing case manager in the community. Mullahy (2010) emphasizes that this

resistance to approve for more services and resources is related to limited funding among

government programs such as Medicare and Medicaid (p. 229). Not everyone can receive
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Running Head: ROLE OF COMMUNITY CASE MANAGER

healthcare under America’s current system, and it is the case manager’s duty to facilitate in

determining who would best benefit from receiving outside assistance such as patients who have

multiple chronic health conditions. Alternatively, for insurance companies that are for-profit and

benefit from denying services to patients, it is the case manager’s duty to advocate for the

patient.

Negotiation. Yamamoto and Lucey (2005), describe negotiation as the act of arriving at a

common agreement through compromising or settling (p. 170). For case managers, negotiation

means that limited resources such as medical equipment, space, and services must be properly

distributed by finding a middle ground between the cost of healthcare and what the patient,

patient’s family, and the patient’s healthcare provider feel are needed to provide care in the home

environment. Mullahy (2010) argues that in order to effectively negotiate care in the community

environment, case managers need to develop collaborative interfaces with all members including

patients, patient’s family members, healthcare providers, government agencies, and payers of

services (pp. 691-92). Community case managers need to voice their concerns on behalf of their

patients despite feeling pressured to succumb to other healthcare providers to cater to their needs

over the patient’s needs.

Values. Strong personal ethics should be the driving force in determining the best

outcomes for patients. Mullahy (2010) asserts that in order to be a patient advocate, case

managers should be held morally accountable to their patients and not to other members of the

healthcare team (p. 140-691). By becoming a patient advocate while properly using limited

resources, community case managers can provide morally sound care. Furthermore, Mullahy

emphasizes the need for case managers to practice ethically and cites the Code of Professional

Conduct for Case Mangers as the golden standard for professional behavior. The code of conduct
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Running Head: ROLE OF COMMUNITY CASE MANAGER

covers such area as maintaining integrity in dealing with other professionals, respecting the right

of patients, obeying laws and regulations, retaining patient privacy, and disclosing benefits and

disadvantages to services.

Change Agent. Case management is more than just a service that nursing provides to the

community. Community-based case management patterns the overall nursing process in terms of

its delivery system by assessing, planning, implementing, coordinating, and evaluating the care

of patient (Yamamoto & Lucey, 2005, pp. 167-169). Mullahy (2010) proposes that many believe

that by transferring nursing’s critical thinking skills into the community environment where more

elderly are receiving ongoing care, American healthcare will transform. The suggestion that the

community case manager can act as a change agent for the entire healthcare system is based

upon case management’s history of being developed to find resources with limited finances (p.

653). The direct-to-consumer case manager is the pivotal link in reducing hospital admissions,

reducing the number of repetitive services, and acting as the negotiator for all members of the

treatment team. In this way, hard assets may be earned in the way of finances, and soft assets

may be earned through better, more efficient care.

Mullahy (2010) addresses case managers who want to take a more active role in

addressing some of America’s greatest concerns by suggesting that case managers follow, “The

State of Aging Health in America 2007” (p. 655). In this call to action, Mullahy suggests that

case managers address disparities in racial and ethnic minorities in the aging population,

encourage patients to communicate their wishes, improve the oral health of the again, encourage

increased physical activity among the elderly, increase the number of elderly who are being

immunized, increase the number of elderly who are being screened for colorectal cancer, and

reduce the number of falls among the elderly.

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Running Head: ROLE OF COMMUNITY CASE MANAGER

Restrictions and Regulations. Not all communities are equal in their ability to handle the

complex social issues that maintaining a sicker population in the home environment creates.

Austin, McClelland, and Gurasansky report that limited community resources for patients with

multiple co-morbid conditions is a major challenge for direct-to-consumer managers who are

focused on finding and directing resources for their patients (as cited by Vinton, Crook, &

LeMaster, 2006, p.164). According to Bowman, Klemzack, and Wehrwein (n. d.), more barriers

to resources are related to lack of transportation to and from services that are not local (p .2)

These challenges are compounded by the community-based case manager’s high workloads,

multiple forms and data entry systems, and authorization requirements which prohibits the case

manager from personally developing programs that would meet the needs of their patients needs

(Austin, Guransky, & McClelland, 2006; Mullahy, 2010). Thus, limited time coupled with too

many patients prevents the community case manager from fulfilling everyone’s goals for

healthcare.

Ongoing healthcare in the community does not reduce regulations imposed by

government programs such as Medicare and Medicaid. Mullahy (2010) explains that these issues

are largely the result of an inadequate financial structure to meet the needs of an aging

populations and patients who are dependent on expensive medical treatments that have only been

created in the last several decades (pp. 741-52). Regulations imposed sometimes prevents

patients from being treated by the most desirable physicians or physicians in specialty areas

because the reimbursement that government programs offer is considerably lower than private

insurance companies. This presents a challenge for the community case manager who cannot

always recommend the highest quality of treatments and providers to their patients even when

their patients have complicated medical conditions.

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Running Head: ROLE OF COMMUNITY CASE MANAGER

Great Man Theory

Management theories can be applied to every area of nursing, including community case

management. The Great Man Theory is one of the oldest theories of management that can be

applied to one of nursing’s newest healthcare environments. Tomey (2008) explains that the

Great Man Theory is based on the idea that certain people inherit traits that are necessary to

become leaders of an industry, while others inherit traits that do not make them necessarily great

leaders (p. 165). Additionally, Tomey describes how those who possess the best leadership skills

understand how to obtain and allocate resources so that people, equipment, materials, and space

can be best utilized. Since community case management places great emphasis on the provision

and relocation of resources according to the needs of the individual while keeping cost at a

minimum, it can be seen how the Great Man Theory can be applied to management in the

community setting.

The premise that certain traits are more desirable or suited toward community case

management is the focus of Mullahy (2010) who generated a questionnaire for current case

managers. (pp. 691-2). This self-assessment was formed with the assumption that those who

respond “yes” to most of the questions would be well-suited to be direct-to-consumer case

managers over those case managers who responded “no” to most questions. The questions ask

specifics in leadership skills such as if the person could become their own boss, if the person

possesses self-discipline, self-motivation, and confidence in order to manage their own business,

and if the person possesses the necessary patient advocacy skills so that the necessary

collaboration can be made to distribute community resources. In this way, behaviors that certain

people possess more naturally than others allows community-based case managers to accomplish

everyone’s goals of doing what is best for the patient, providing high quality of care, and
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Running Head: ROLE OF COMMUNITY CASE MANAGER

containing costs. Nurses in the community can thus become the change agents necessary to

reengineer the healthcare system.

Conclusion

Case management is an evolving nursing specialty that will continue expansion into the

community environment as health care needs change to meet the individual’s health concerns.

Community-based case managers take on more roles than simply locating and directing

resources for community members and are concerned about safe care and the overall well-being

of their patients. The characteristics needed to be a good case manager in the community are

consistent with those found in other areas of management and nursing and include having good

organizational, advocacy, communication, and negotiation skills. Working within the community

presents different challenges than nurses face in the hospital setting and includes resistance in

patients and payers with treatment plans, difficulties negotiating service agreements, conflicting

value systems, the responsibility of having to act as a change agent for healthcare in general, the

restrictions in time and resources that community case managers face, and the regulations that

they must follow even in the community setting. Additionally, the Great Man Theory was

discussed in relation to how it can be applied to the characteristics desired to be an exceptional

community case manager.