Strategies for Case Managers’ Advocacy

Case managers in any care setting often act as members of “collaborative interdisciplinary care teams” usually composed of providers (i.e., physicians, nurse practitioners, and physician assistants), case managers, registered nurses, social workers, physical and occupational therapists, utilization managers, psychologists, pharmacists, and other professionals and paraprofessionals (e.g., community health workers, health educators, navigators, and client advocates). Skillful and agile case managers apply several advocacy strategies in their daily interactions with clients, payers, and collaborative team members and while navigating the complex health care system. A common goal when applying any of the strategies is facilitating the clients’ access to required services and resources. A primary advocacy strategy, commonly used by case managers in care delivery, is “doing the right thing.” It is directly linked to the best interest of the client. Doing the right thing can be described as the delivery of care and services that are proper, indicated by the client’s condition, and preferred by the client and client’s support system. It is optimal in that care is provided in the most appropriate care setting and by the provider of choice, and that it meets the wishes and preferences of the client. This protects the client’s autonomy, right to choice, self-determination, and informed decision making.

Doing the right thing also means that case managers ensure that health care professionals provide clients with the type of services they need based on their medical and socioeconomic condition and including the necessary tests, procedures, and treatments, and that they are completed expeditiously and safely. Importantly however, doing the right thing is seen by case managers as a function of quality of care, safety, continuity of care, common goals, collaboration, and teamwork among the various disciplines involved in the care of the individual client/support system.

Another strategy that is closely related to advocacy, and that is aligned with doing the right thing, is care coordination. It is defined as a comprehensive process of planning, delivering, coordinating, and monitoring of health care services, while meeting the needs of the clients and their support systems, ensuring cost-effectiveness and safe, quality care. The emphasis in this strategy is on the client, similar to “doing the right thing.” Case managers coordinate the health care services needed by their clients across the continuum of care and diverse providers. They also focus on meeting the clients’ physical, emotional, psychological, spiritual, financial, and cultural needs through the coordination of care activities and communication among the various care providers. Care coordination-related advocacy activities encompass assisting clients to return to their baseline lifestyle and health condition or getting to the highest level of function that they can get to. Such activities are client-centered, directed, and focused. Integral to care coordination is the emphasis on the clients defining their needs for advocacy based on informed and shared decision-making, and then case managers as client advocates support their clients in taking direct action toward fulfilling the goals (i.e., client empowerment and engagement).

When ethical dilemmas or disagreements concerning client care and treatment options arise, case managers may apply the “case conferencing” method as a strategy in resolving the ethical and other concerns that facilitates clients’ ability for informed and shared decision-making. Case conferencing is relevant to advocacy because it is used as a conflict-resolution process and a method to educate the client and/or client’s support system about care and to discuss decisions such as stopping treatment, withdrawal of life support, and do-not-resuscitate status. Case conferencing is also useful in situations when clients and their support systems are unclear about diagnosis, prognosis, length of treatment, or the transition/disposition plan. Decisions made during case conferences are resolutions to issues at hand and are to the clients’ satisfaction. Acknowledging and addressing the needs of the clients and their support systems reflect the case manager’s duty as an advocate. This advocacy approach allows clients/support systems to voice their opinions (i.e., having a voice and defining an existing problem from their own perspective), and emphasizes the role of case managers as advocates in assisting them in addressing their self-defined needs (i.e., client-centered and culturally competent care). It also provides clients with a concrete opportunity to identify alternate and creative solutions to the issues or concerns rather than just accepting the status quo. This also promotes advocacy as an active event rather than as a passive event, that is, clients owning the resolution of concerns in collaboration with the case managers to meet their self-defined desires.

Outcomes management is a strategy that is aligned with advocacy because of its intense client focus. Outcomes management involves tracking, monitoring, and data analysis regarding care delivery, patient care outcomes, delays in treatments, tests and procedures, risk management concerns, and reimbursement issues and denials. Outcomes management is necessary for evaluating the consequences of care delivery and allows the collaborative interdisciplinary care team to examine whether the needs of the clients are met and to what extent (i.e., quality of care, safety, and care experience). The process of determining outcomes begins with reviewing the client’s record, to collect data such as clinical care outcome indicators, delays in tests or procedures, and risk management issues. Through outcomes management, case managers ensure that the clients gain access to necessary resources and that their needs are met and in a timely fashion. Through outcomes management, case managers as advocates can focus on assessing the impact of their actions on the well-being of clients and their support systems, development of self-management skills (i.e., engagement), understanding of health conditions and plans of care, and ultimately empowerment.

Advocacy strategies case managers employ in their daily practice are not limited only to doing the right thing, care coordination, case conferencing, and outcomes monitoring. Other examples that advance their roles as client advocates are summarized later.

1. Communicating among team members, with the client and client’s support system, and with the members of internal (health care agency-based) and external (outside the health care agency such as transportation and durable medical equipment vendors) teams to discuss care, services, and related issues. A special focus of advocacy here is “respect for the client wishes and choices” and “empowering the client to voice own thoughts.”
2. Teaching to ensure that the client and other members of the health care team are kept informed and knowledgeable of health insurance or managed care regulations and statutes, the decision-making processes of the insurance companies, and the procedures of denials and appeals. Teaching also focuses on increasing the client’s knowledge of their health insurance benefits, plan of care, how to change or reduce illness-related risk factors, how to navigate the health care system, when to engage in follow-up care, and how to care for self while at home.
3. Resolving Disagreements that might arise between members of the different teams involved in a client’s care, between themselves and the client, or between the client and members of the client’s support system. The activity focuses primarily on client’s safety and good health and promotes client’s autonomy, self-determination, and shared decision-making.
4. Brokering of Services to ensure that appropriate care options and resources are arranged for and made available to the client while in the hospital setting (or during an episode of illness), upon or at the time of discharge, or after discharge and while in the community. This activity aims to ensure the client’s access to the health and human services they need or are interested in. When brokering services for their clients, case managers encourage clients to voice their desires and preferences and operate based on already-established mutually agreed-upon goals.
5. Obtaining Informed Consent from the client for treatments to be provided and tests and procedures to be completed. It is also necessary to confirm that the clients grant the case manager permission to appeal on their behalf the decisions made by insurance companies to deny services or reimbursement for care rendered. The case manager facilitates the clients’ informed decision and respects their right to choice.
6. Supporting, that is, to provide clients and their families with emotional support and counseling as needed to reduce their anxiety and apprehension during the episode of illness and the course of treatment. It may also mean working with the client and support system to realize that they have to assume responsibility for their care and related decisions. This activity allows case managers to assist clients in their efforts to navigate the complex health care system by developing needed skills in self-management, acquiring necessary knowledge, and clarifying areas of confusion.
7. Appealing denials according to stipulations of contractual agreements between the health care agency/provider and the insurance company (payer). This is made in an effort to ensure that the agency receives reimbursement for care provided and that the clients receive the care and services needed as necessitated by their medical and health conditions. A major purpose of advocacy in appealing denials is ensuring the client’s access to needed services.
8. Going above and beyond to ensure that the clients’ needs, both direct and indirect, are met. This activity focuses on looking beyond the obvious care needs. For example, if a client is hospitalized and has a pet left alone at home, in addition to ensuring that the client’s medical needs are met, the case manager devises a safe plan for the pet as well. This also includes activities the case manager may take to ensure that the client’s experience of care is optimal. By going above and beyond, case managers demonstrate advocacy for the provision of culturally competent and client-centered care. This also provides the client to articulate self-defined goals.
9. Establishing relationships with varied members of the health care team internal and external to the health care agency and as necessary for better delivery of care and services. This is important for effective coordination and management of care and outcomes. Establishing a trusting case manager–client relationship enhances the case manager’s ability to advocate effectively with the members of the health care team on behalf on the client.