Presentation delivered in my Community Health Worker class.

1. Chapter 10: Care Management

2. 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

3. What is Care Management?
 https://www.youtube.com/watch?v=E47VI_xA6qg

4. 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.

5. 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

6. 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

7. Elements of Care Management
 https://www.youtube.com/watch?v=0ajk2hEHQ-M

8. 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

9. 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

10. 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

11. 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?

12. 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

13. 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

14. 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

15. Stages of Care Management
1) Initial assessment of strengths, needs, and priorities
2) Development of clear goals and steps to achieve those goals
3) Implementation of the care management plan and monitoring of progress
4) Completion or end of care management (sometimes referred to as discharge or termination)

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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.)

33. 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

34. 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?

35. 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

36. 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

37. 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

38. 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

39. 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”

40. 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

41. Similarities
 Ecological framework
 Systems perspective
 Ethics
 Cultural humility
 Client-centered skills
 Action planning

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. Importance of Clear and Effective Documentation
 https://www.youtube.com/watch?v=FZdkOwUC9LU