Chapter 10: Care Management

You Will Learn:

You will be to: Define care management Explain your scope of practice as a care manager Understand the differences and similarities between working with an individual versus working with

families as your client Analyze and examine concepts of gender identity and working with transgender and gender

nonconforming communities Work with clients from a strength-based perspective to identify both strengths and needs Support clients to develop a detailed care management plan designed to promote their health and

well-being Identify and provide meaningful referrals to community resources Organize your work and manage your files Clearly document the care management services you provide

What is Care Management?

https://www.youtube.com/watch?v=E47VI_xA6qg

Defining Care Management

Assisting consumers and their support system to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively

The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective non-duplicative services

Care management is provided on an ongoing basis and the length of time can vary Care management services are provided in various locations, including your office, a

client’s home, hospital, jail/prison, homeless shelter, streets, over the phone, etc.

Roles in Care Management

Care managers must provide services in a client-centered way and support the autonomy and empowerment of the client

Care managers support clients and help to create a realistic plan to promote health and well-being and to take actions to implement the plan

Care managers link clients to resources, programs, and services to enhance the clients health and safety

Care managers help clients navigate the healthcare and health insurance system Care managers encourage self-empowerment, assist in short- and long-term goal

planning, advocate for necessary services, and offer peer counseling

Importance of Conducting Care Management

CHWs have demonstrated effectiveness in working in team settings and coordinating care

Able to develop a trusting relationship between patients, the community, and healthcare system

CHWs must be the culturally competent mediators https://www.youtube.com/watch?v=RaUw0b_BNJ0

Elements of Care Management

https://www.youtube.com/watch?v=0ajk2hEHQ-M

Elements of Care Management

Work from a strength-based perspective that emphasizes a client’s internal and external resources Support the autonomy and decisions of clients Support clients in developing their own action plans that include clear goals, priorities, and realistic actions to achieve these goals Practice cultural humility: don’t make assumptions about the knowledge, behaviors, or values of your clients or impose your own

cultural norms Provide client-centered education and counseling, as necessary, about the health issues or conditions relevant to the client Understand the three phases of care management and when to end services Develop an in-depth understanding of available basic resources and services and maintain ongoing professional relationships with

these service providers Provide clients with referrals to resources, including clear guidance about why and how to access these resources Set boundaries and stay within your scope of practice Consult regularly with a supervisor and or members of your program or clinic team Manage client files and stay organized Document your work accurately Present and discuss your work with individual clients to the health care team or your program coordinator or supervisor Accept feedback and be open to examining your own assumptions or bias

Strength-Based Care Management

Be aware of focusing too much on the needs, problems, and/or challenges that clients face and resources they lack Needed to identify basic resources that will promote the health of the client But can reinforce low self-esteem

Be sure to incorporate the client’s strengths, talents, achievements, and available resources

Working as a Team

Care managers play an important role in a care team that could additionally include: the client, a supervisor, social workers, nurses, or physicians

Important to work well together and to collaborate regularly to discuss care Important each member understands their own scope of practice and their role is

clearly defined

How to NOT be a Care Manager

https://www.youtube.com/watch?v=VayIpAuSQAI What were some of the things the care manager did wrong?

Client Responsibilities

Decide to participate in care management Decide whom to work with, and provide informed consent to work together Provide accurate information in a confidential setting Identify strengths and needs Identify goals and develop a realistic plan of actions to meet those goals Communicate regularly with other members of the care management team, and attend appointments or call in advance to

cancel if necessary Decide which other providers, if any, the care management team can share confidential information with Ask questions and raise concerns related to care management services Strive to learn new information and skills to enhance their health and well-being Identify additional services they are interested in accessing, and speak up if they are reluctant to access a particular service Follow prescribed treatments and use of medications and communicate with the team if challenges or concerns arise Actively participate in deciding when and how to end care management

Care Manager Responsibilities

Conduct an initial assessment with clients; orient individuals or families to the program, services, and policies, including confidentiality Obtain informed consent to provide services Honor principles of client-centered practice, including the client’s right to self-determination Work with the client to assess their strengths or internal and external resources, their health risks and priorities, and services that they would like to access Work with the client to develop a written care management plan and monitor progress in meeting identified goals and priorities Maintain proper documentation of all services provided and the challenges and progress made in the implementation of the care management plan Provide clients with referrals to additional resources and services (make sure services are culturally appropriate, accurate, up to date, and if possible, provide

a direct contact) Maintain client confidentiality as required by law and agency policy Work professionally and ethically to provide quality service Ask for and obtain the client’s permission before releasing information to other providers Reinforce health education knowledge and skills Maintain contact with clients and monitor and document their progress Conduct home visits if appropriate Advocate for client needs and priorities Participate in conferences with colleagues to discuss care management challenges and successes Participate in regular supervision sessions, clearly identifying challenges, concerns, and questions that arise in your work with clients Advise others working with your clients about changes within the community that might impact the clinic or program

Health Care Provider Responsibilities

Provide clinical care, including g diagnosis of illness and prescription of treatments in accordance with established protocols

Establish and maintain communication systems with other team members, departments, hospitals, and community organizations and agencies so that referral systems function smoothly and promote continuity of care

Work with others to develop referral protocols, entry/exclusion/exit criteria, and clinical management protocols

Obtain informed consent and necessary releases to share information with other health care providers Coordinate medical care services, including referrals for lab work and to specialists, as appropriate Maintain appropriate documentation of clinical services Participate in conferences with colleagues to discuss care management challenges and successes Provide program updates and share outcome data, maintaining client confidentiality

Stages of Care Management

1) Initial assessment of strengths, needs, and priorities2) Development of clear goals and steps to achieve those goals3) Implementation of the care management plan and monitoring of progress4) Completion or end of care management (sometimes referred to as discharge or

termination)

Care Management Plan

Focus is to develop a client-centered plan documenting the strengths, needs, clear goals, and actions that will be taken to promote the client’s health and well-being

A working document to keep everyone focused on the desired goals and how to achieve these goals

The care plan will depend on the needs and particular issues unique to each client Should assist clients in developing knowledge and skills to aid them to stay

independent and to successfully manage future challenges on their own

The 1st Meeting

Welcome the client and assist the person to feel comfortable Build rapport and a trusting relationship Explain the nature and extent of the services that you can provide Describe any program restrictions and/or costs Explain the limits of client confidentiality and other essential program policies Answer the client’s questions and concerns Obtain informed consent to proceed with the assessment process Explain the types of questions you will ask as part of the assessment and the purpose

for the questions

Confidentiality and Release of Information

Must be aware not to share confidential information with other service providers unless they are part of the care management team or the patient has given you permission May be helpful for the patient and/or provide better coordinated care

Must discuss with the client and agree to share information with another provider Client must sign a release of information (ROI) form that clearly identifies the client,

service providers, agency of the provider, and the services that the agency provides ROI will detail the kind of information to be shared, why, and when the agreement will

expire or end

Developing a Care Management Plan

Includes: An assessment of the client’s strengths and existing resources An assessment of the client’s risks and need for additional resources The development of one or more goals or objectives to improve the quality of the client’s life The development of a detailed action plan outlining steps designed to reach identified goals or

objectives The documentation of who is responsible for putting each step into action The documentation of referrals provided and accessed and outcomes The progress notes The documentation of the end of care management services (discharge or termination) Signature by client, family, care manager, or other team member

Conducting an Assessment

Establish a clear understanding of the client’s primary concerns, strengths, and needs Used to guide the development of a care management plan

Gather 3 types of information: Basic demographic information Strengths- internal or external resources Current risks and needs

In asking questions, start with the least invasive and uncomfortable questions first Work to establish a positive professional connection

Gender Identity and Sexual Orientation

Growing recognition in medicine and public health of a diverse range of gender identities Gender identity- an individual’s internal sense of being male, female, both, neither, or something

else Not necessarily visible to others Transgender, gender variant, cisgender

Sexual orientation- a self-identity that describes a sense of how individuals are attracted to other individuals, or not

Heterosexual, bisexual, asexual, pansexual https://www.youtube.com/watch?v=Vlx9iZ9g_9I

Practicing Cultural Humility

Important to remember cultural humility and understand some of the unique difficulties some clients may face Discrimination, rejection, fear

Important to practice cultural humility when conducting the initial assessment to not make judgments based on appearance and to understand some reluctance to answer questions

Refer to client by their preferred names and pronouns Know local laws and policies regarding gender identity discrimination to support clients Understand options that clients may take in hormone replacement therapy and the effects

that this and other violence and harassment issues may take on the client’s health Body changes, chronic stress, depression, anxiety, substance abuse, etc.

Learning a Client’s Identity

A client may or may not share their gender identity Client-centered practices

Have the client fill out relevant forms Ask how they identify or what identities are important to them Provide your client with opportunities to share information

Assessing the Client’s Strengths and Available Resources

Emphasize the importance of assessing, valuing, and building on client’s strengths Assist the client to recognize what they have, what they can do, and what they have

accomplished Helps to identify all of the resources available and aids in building confidence,

capacity, and autonomy May not all happen at once, but will occur as you develop a working relationship

Assessing the Client’s Risks and Need for Additional Resources

Identify current life challenges, risks, and needs for additional resources Housing, interpretation services, substance abuse treatment, employment, legal assistance, risky

exposures, current sexual behaviors, current infections, etc. Open-ended questions

What are you most concerned about now? What are the biggest risks to your health? What is the biggest challenge you face right now?

Assist the client in prioritizing their own risks and needs May provide health education for a diagnosis to improve treatment adherence, reduce

symptoms, and enhance health May provide some client-centered counseling for risk reduction and behavior change

Identifying Care Management Goals

Based on the assessment, support the client in identifying one or more specific goals for the care management plan

Life goals are important but try to focus on more immediate concerns Goals should come from the client, be specific, and be realistic

Set the client up for success not failure

Establishing Care Management Priorities: The Client’s Plan

https://www.youtube.com/watch?v=isOQoAF4kAA Care manager priorities may be different than the client’s priorities Provide them with information, referrals, and guidance about their priorities and

actions for enhancing their health and well-being The client will decide whether or not to accept or reject your help Respect client priorities

May not immediately be what you think should be priority, but addressing their goals and needs first helps to build trust and small successes

https://www.youtube.com/watch?v=uX65IjyHV6k

Developing an Action Plan

Make a plan to reach the client’s goal(s) Identify who is responsible for each action and provide a time line for completing these

actions Care managers

Referral resources, release forms, health education, counseling, and advocating to other service providers Clients

Changing diet and exercise, practicing stress management, reducing substance abuse, reducing risky behaviors, take an active role in improving their health

Time frame depends on the issues, difficulty of steps, and the individual or family’s strengths and risks

Start with steps that are less intimidating and seem most possible

Coordinate with Other Care Management Team Members

Collaborate with the team to develop the care management plan All members should attend regular meetings to monitor progress and any need to

revise the care management plan The client may feel that some or all of the services are not working

May ask for changes, may withdraw from services, new needs may become more important, stop progressing

Reassess, revise the action plan or goals, and/or the care manager may need to assume additional responsibilities

Don’t change the plan so often that no progress can be made, but don’t let the plan be so rigid that the client wastes time on a plan that does not promote his/her health and welfare

Documenting Progress

Document each contact you have with the client or other service provider working with the client In-person, phone, online, and mail

Document accomplishments and challenges

Ending Care Management Services

Discharge or termination may be decided by the client and care manager, but clients may decide to discontinue services

Discharge may occur when clients have successfully implemented key elements of their action plans and enhanced their health or well-being

Should be a planned transition to independence and discuss: What has been learned and/or accomplished The client’s internal and external resources Relapse prevention What to do when faced with challenges or crises in the future

Thank the client and congratulate them on their successes

Effective Care Management

Keep in touch with clients Business phone numbers and email addresses with best times to contact and return message

times Professional boundaries- no personal numbers

Ask for best contact for clients (Ex. neighbor’s phone, relatives, shelter, housing agency, etc.)

Effective Care Management

Key times to offer guidance Respect the right of the client to make their own decisions

Important concept of client-centered practice This does not mean that you will or should always agree with or accept the client’s ideas,

plan, or actions There are times when it is important to speak up, gently confront or challenge your clients,

and to offer them guidance Clients establish unrealistic goals or expectations of themselves Clients have unrealistic expectations of you or others Clients engage in unsafe or harmful behaviors

Unrealistic Goals/Expectations for Themselves

May develop goals that are overly ambitious Scenario:

Client with diabetes and high blood pressure along with a long history of dieting and no physical activity. Client decides to start working out at a local gym every morning for 1 hour and eliminating all sugar from his diet.

What are some potential problems? How could you make this goal more manageable?

Unrealistic Goals/Expectations for Themselves

Possible Problems: Setting up for failure, cause a negative outlook, relapse to unhealthy behavior, drop out of care

management Possible Solutions:

Remind them that some changes may take a while and that it is best to make small changes rather than all at once

Encourage and praise motivation for being healthier Suggest and discuss smaller objectives to reach overall goal

Goals that will give immediate success More realistic goals to build up success Listen to the client to understand why they have certain goals and make sure that the client decides

what steps to take

Unrealistic Expectations of You or Others

Be aware of clients who put all hope in you or others to ensure that they succeed in their care plan

Some may put all their hope into a particular resource such as housing, disability, a settlement, etc.

Help them to plan and cope with big disappointments or setbacks

Unsafe or Harmful Behaviors/Choices

Take action to prevent harm or further harm with clients who are considering harming or actively harming themselves or someone else

Effective Care Management

Advocate for your client Clients may not be successful accessing resources they are referred to

Goal is to support clients in managing their own lives and health, so part of that is learning how to advocate for themselves

Be aware of stepping in on their behalf too soon to prevent dependency Support your client in developing the skills and confidence to advocate for themselves May be times when you need to step in to help access resources- balance Make calls together, practice calls, ask client questions, follow-up with client after they make

their own contact to ask what went well and any concerns

Common Challenges

Clients with serious health problems and life challenges May be scared, frustrated, angry, and/or suspicious of help

Important here to build trusting relationships and listen May not always be honest and may complain to others about you May have diagnosed or undiagnosed mental health issues and may not be under

treatment May have substance abuse problems May not be able to effectively communicate their needs Important to not judge, stigmatize, or discriminate the “difficult clients”

Working with Families

Families can have positive or negative impacts and create the structure for our understanding of the world How and who to be, economic factors, divorce, conflict or abuse, alcoholism, etc.

Family structures are diverse and will require cultural humility if you are unfamiliar with the family structure Age and generation Partnership and parenting status Status of children Ethnicity Gender and gender identity Sexual orientation Immigration status Religious or political affiliation

Important to remember that in order to change a part of the system you will have to consider the effect on the rest of the system

Work to reframe the identified patient and focus on the system as a whole

Similarities

Ecological framework Systems perspective Ethics Cultural humility Client-centered skills Action planning

Key Differences

Individuals One person who is the client Prioritize the health goals and concerns

of an individual Focus on supporting an individual to

take action to create change and promote health

Strive for individual balance

Families Working with two or more people- family

is the client Prioritize the health goals and concerns

of the family system Focus on supporting the family system

to take actions to create change and promote the health of the family system as a whole

Strive for family system balance

Community Resources and Referrals

Be familiar with local resources Housing, legal assistance, employment training, job counseling, education, child care, health

care, mental health care, drug treatment, etc. Other resources?

May already be available and may have to develop your own Keep resources up to date Build relationships with contacts https://www.youtube.com/watch?v=xKJQ06HExq4

Resource Guide

Categorize and organize resources Name, address, website, and contact for agency or service List the services provided and any costs Eligibility requirements and required documents for registration and/or appointments Hours of operation and directions

Effective Referrals

Strong interest to the client Explain the referral and the services provided Clear guidance about who, how, when, and where to access the program/agency Culturally and linguistically appropriate Written summary Contact agency you referred the client to Follow up with the client https://www.youtube.com/watch?v=SzY0L5tA4DU https://www.youtube.com/watch?v=2GoI8gJGSZg

Organization and Documentation

Make a schedule and keep it Helps to prevent burnout

Manage case file Accurate documentation and maintenance of case files are essential for funding

Provides insight and depth to the quality of your work and helps to evaluate your performance Records in case of legal issues Used to understand a client’s progress

Documentation Guidelines

Explain to clients Keep files confidential Alphabetize files Use appropriate forms Write clearly Keep data in a consistent order Keep files up-to-date

SOAP Notes

S: Subjective What clients report to you, things they say have happened, how they feel about it, etc.

O: Objective What you observe and hear during meetings and conversations with clients- no interpretation

or analysis A: Assessment

Your own thoughts, interpretations, and analysis P: Plan

What you and the client plan to do in the future https://www.youtube.com/watch?v=9TZqTtbBVXc

Case Conferences

Bringing together members of a team who work with the same or similar clients Purpose:

Improve the quality of services provided to clients Improve coordination between service providers and service teams Enhance the professional skills of service providers

Importance of Clear and Effective Documentation

https://www.youtube.com/watch?v=FZdkOwUC9LU