• Client Identification and Selection
• Assessment and Problem/Opportunity Identification
• Development of the CM Plan
• Implementation and Coordination of Care Activities
• Evaluation of the CM Pln and Follow-Up
• Termination of the CM Process

These components in the CM process do not differ a great deal from the six Standards of Care identified in the 2002 Standards of Practice. However, the steps listed in the above CM process are not intended to be 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.

The CM process is carried out using critical-thinking and evidence-based knowledge. It is not the intent of the 2010 SOP to parallel key responsibilities of CM, but rather to broadly define major functions involved in the CM process to achieve desired outcomes.

One of the biggest changes in the 2010 SOP is how each Standard is to be demonstrated by the case manager. In the 2002 SOP each of the six Standards of Care was followed by a Measurement Guideline which the case manager would "seek" to accomplish. However, in the 2010 revision, each of the 15 Standards of CM Practice is followed by specific documentation or actions needed to "demonstrate" that the Standard was met by the case manager.

Below is a brief review of the first four Standards of CM Practice. In this column I can only give a partial listing of how each Standard of CM is to be demonstrated. I would encourage each of you to take the time to look more closely at this important refinement of the 2010 SOP.

Standards of Case Management Practice

A. Client Selection Process for CM The case manager should identify and select clients who can most benefit from case management services available in a particular practice setting. Demonstrated By:

• 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 CM programs (i.e. poor pain control; repeated emergency department visits; repeated admissions; poor nutritional status; financial issues).

B. Client Assessment
The case manager should complete a health and psychosocial assessment, taking into account the cultural and linguistic needs of each client. Demonstrated By:
 

• Documentation of client assessment using standardized tools, when appropriate, as pertinent to the CM's practice setting (i.e. client strengths and abilities; health status expectations and goals; transitional or discharge plan; advance care planning; health literacy and illiteracy; readiness to change).
• Documentation of resource utilization and cost management; current diagnosis(es); goals (short and long term); provider options; and available health care benefits.
• Evidence of use of relevant, comprehensive information and data required for client assessment from many sources (i.e. client interviews; family, providers, other members of the interdisciplinary health care team; data, claims and/or adminstrative).

C. Problem/Opportunity Identification
The case manager should identify problems or opportunities that would benefit from case management intervention. Demonstrated By:
 

• Documentation of agreement among the client, caregiver and other providers and organizations regarding the problems/opportunities identified.
• Documented identification of opportunities for intervention (i.e. non-adherence to plan of care; lack of education or understanding; inappropriate discharge or delay from other levels of care; frequent transitions between settings).

D. 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. Demonstrated By:

• Documentation of relevent, comprehensive information and data using interviews, research, and other methods needed to develop a plan of care.
• Validation that the plan of care is consistent with evidence-based practice, when such guidelines are available and applicable.
• Documentation of client's or client's support system participation in the written case management plan of car; documentation of agreement with plan, including agreement with any changes or additions.
• Facilitation of problem-solving and conflict resolution.
• Evident of supplying the client with information and resources necessary to make informed decisions.
• Compliance with payer expectations with respect to how often to contact and reevaluate the client or redefine long or short term goals.