Client advocacy is a complex process and a key role of case managers. It demands specific skills, knowledge, and competencies from case managers to ensure that clients and their support systems receive effective advocacy and that their rights and interests are protected at all times. Advocacy efforts aim to build trusting relationships, facilitate a common understanding among those involved in care provision including the client/support system, ensure the discussion and support of the client’s views and wishes, raise relevant issues on behalf of the client, protect the client’s rights, autonomy, and best interest, eliminate barriers, maintain fair and equitable access to client-centered care, and effect quality and safe outcomes. These goals require astute case managers and competent client advocates, individuals with specialized skills, knowledge, and competencies. Therefore, it is necessary for case management leaders to develop and implement specific client advocacy competencies for case managers. It is important that these leaders also design and offer case managers targeted training and education programs in this area to ensure that they possess appropriate knowledge and skills in the client advocacy key role.
Client advocacy in case management practice involves identifying the actual and potential unmet needs of clients and taking action to change the circumstances that have or potentially may contribute to such deficiency. This practice is not strange to case managers; they often identify actual or potential barriers to care (i.e., delays in services) and intentionally intervene to either prevent the occurrence of the barrier or minimize its effect on the client. Because advocacy is inherent in every aspect of case management practice, a case manager is not considered a proficient or expert practitioner unless if he or she specifically demonstrates competence in client advocacy.
Case managers must possess appropriate level of skills, knowledge, and expertise in advocacy to perform their advocacy roles effectively and be taken seriously by their clients/support systems, peers, and other health care professionals. Availability of support, mentoring, and training for case managers in advocacy are an important step toward enhancing competence. To develop a program of case management competence, it is necessary to first be clear about its aims, infrastructure, processes, standards, ethical principles, and expected behaviors and outcomes. These constitute the foundational characteristics of advocacy and illuminate the expected knowledge, skills, and behaviors of case managers that are demonstrative of competence in the role of client advocate. As it is the case in the literature on competence, the program of case management advocacy competencies must consist of clearly articulated behaviors or dispositions and their requisite knowledge and skills as well as their expected outcomes (see Table 3).
TABLE 3 – Competencies of Case Management Client Advocacy
| Elements | Highlights and Examples |
|---|---|
| Key competency topics | Disposition of the advocacy role |
| Client support and respect for autonomy, self-determination, and right to choice | |
| Ethical and moral disposition | |
| Promotion of client empowerment and engagement | |
| Ensuring equity and fairness in access to care and distribution of resources | |
| Client-centeredness and cultural sensitivity | |
| Essential and requisite knowledge areas | Code of ethics and professional conduct |
| Principles of ethics and client’s advocacy | |
| Theories and approaches to advocacy | |
| Process of advocacy | |
| Types and levels of advocacy | |
| Standards of case management practice | |
| Facilitators and challenges of client advocacy | |
| Stages of client advocacy: reaching a state of empowerment and engagement | |
| Model of client advocacy | |
| Requisite skills | Building a trusting client–case manager relationship |
| Advocacy disposition style: thoughtfulness, sensitivity, respect, and inclusivity | |
| Communication and listening skills | |
| Problem identification and resolution | |
| Interprofessional collaboration and teamwork | |
| Motivational interviewing | |
| Negotiation | |
| Identifying ethical dilemmas and ethical decision-making model or process | |
| Expected outcomes | Safe and quality care (reduction in unsafe or significant events, better clinical outcomes) |
| Optimal care experience and satisfaction (increase in scores) | |
| Improved degrees of client activation, empowerment, and self-management | |
| Time and appropriate access to services and resources | |
| Reduced gaps in care | |
| Trusting, respectful, and productive client–case manager relationship | |
| Improved self-reported well-being and self-confidence | |
| Increased involvement in self-advocacy |
Note. © Copyright 2016, Hussein M. Tahan, PhD, RN.
Training and certification programs in client advocacy in health care are beginning to form. These enhance access of case managers to training programs and professional credentials specialized in client advocacy. One example is the Professional Patient Advocate Institute (PPAI), which aims to achieve top-quality care delivery and simplified health care navigation for clients and their support systems. PPAI focuses on the training and education of health care professionals, including case managers, as client advocates to advance their skills for effectively assisting clients and their support systems in navigating the complex health care system. These professionals may also include registered nurses, disability management specialists, physicians, pharmacists, physician assistants, psychologists, health navigators, life care planners, financial or insurance services representatives, behavioral health specialists, social workers, community health workers, and other health care professionals (PPAI, 2016). PPAI essentially promotes the professionalization of advocacy and the development of competencies in this regard. It also perceives that such advocacy results in having advocates who are able to objectively assist consumers in understanding and making sense of their health care needs. This trained and competent professional is then better able to advocate for consumers as they strive to secure their health care needs and cover their insurance and financial matters (PPAI, 2016). Moreover, this professionally trained client advocate, who may be a case manager, becomes more successful in giving consumers a voice, understanding their goals, conducting research, and providing valuable information to help them make informed decisions regarding their health care needs (PPAI, 2016).
Client advocacy competencies of case managers may consist of a variety of behavioral characteristics demonstrative of the following aspects of advocacy:
- disposition of the advocacy role;
- ethical and moral disposition;
- client support and respect for autonomy, self-determination, and right to choice;
- promotion of client empowerment and engagement;
- ensuring equity and fairness in the client’s access to care and distribution of resources; and
- client-centeredness and cultural sensitivity.
Case managers who embrace the role of an advocate engage in the professional disposition of client advocacy in a manner that is integral to their daily execution of the general role of a case manager. Such performance is usually seamless. That is, there is no palpable separation between advocacy and other case management functions. Therefore, advocacy is embedded in all functions, however, to varying degrees as appropriate for the function. These case managers are also autonomous in their thinking and demonstration of advocacy. Moreover, they exhibit motivation, altruism, objectivity, transparency, generous listening, and a genuine concern for clients’ well-being and betterment. Client advocacy comes natural to this type of case managers.
Case managers who are competent client advocates also exhibit knowledge, skills, and comfort in ethical and moral disposition. For example, they are aware of the codes, standards, and principles of ethics of their professional discipline and case management organizations. They also understand the value of ethical decision-making models and their benefit in ethical conflict resolution. Through their personal commitment to the “ethic of caring and compassion” and moral conduct, they are able to develop trusting relationships with their clients/support systems and engage in open and transparent communication. In addition, competent case managers with professional ethical disposition are skillful at engaging clients in self-defining their concerns and taking an active role in resolving them.
In the area of client support and respect for autonomy, self-determination, and right to choice, competent case managers approach their clients as active participants in advocacy. They engage them in exercising their rights, recognition, and endorsement of what is in their best interest, maintaining their independence, and making informed decisions, especially in voicing their wishes and articulating their preferred action plan for overcoming conflicts. An ultimate aim in this competency is the case manager’s ability to create a context of care that is built on “legitimacy of clients defining their own needs, desires, and goals.”
Case managers as effective client advocates demonstrate competence in the promotion of client empowerment and engagement. They reflect such competence by educating and counseling clients about their health conditions and care options so that they adapt to living with the disease and/or limitations they are facing, and acquire the necessary knowledge and skill for self-care and self-management. They also are effective at using motivational interviewing techniques to assist clients to make informed decisions, verbalize their fears and anxieties about self-management, and identify the barriers preventing them from adapting to the limitations imposed upon them by their health conditions.
Ensuring equity and fairness in the client’s access to care and distribution of resources is a competency that focuses on eliminating disparities, prevention of barriers to care, and provision of nondiscriminatory services. It also includes ability to allocate health care resources in ways that meet the preferences and needs of the clients and their support systems. In addition, this competency expects case managers to educate their clients about the range of resources available to them in their communities and arrange access to these resources where needed and is considered appropriate. Client-centeredness and cultural sensitivity are an important competency case managers demonstrate when they respect the individuality of their clients, act in ways that are free of judgment, and provide services that meet the client’s cultural value and belief system.
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