Implications For Case Management Practice Research Articles

Palliative Care Nursing Case Management in Young Adults With Advanced Rare Cancer: Case Discussion of a Multidisciplinary Approach.

Purpose/Objectives: This case aims to identify the elements of care continuity that are lacking in young adult patients with advanced rare cancer, suggesting ways to enhance continuity of care through nurse case manager/management (NCM) interventions and describing their impact on the emotional burden of patients and their families. Primary Practice Setting(s): Comprehensive cancer center. Findings/Conclusions: The dyadic care alliance with the NCM can alleviate disease burden, fostering trust in the team and adherence to care advice, thus reducing the patient's distress. The NCM can be an efficient option to advocate for patient needs on the multidisciplinary team, addressing practical issues and the unmet needs of patients and their caregivers, and facilitating referrals to other professionals. The study also shows that caring for young adults with advanced rare cancers should include mindful evaluation of their significant others. Implications for Case Management Practice:

Can History Change Our Future Course? Lessons From Case Managers Across Time.

Purpose/Objectives: History can tell us a lot. Through the lens of case management history, we can appreciate how our practice has evolved and what have been the sticking points along the way. We can better understand how our practice became knitted into the fabric of the health care system, and why we apply certain functions and processes of case management across different practice settings. Historical lessons captured by national case management organizations or found in the literature can help us think about how to improve the future, as well as the care we deliver today. Higher education is another good resource for honing our skills. As the complex care of patients has evolved over time, there has been growth in advanced case management education (P. Stark, 2020). Yet, not everyone has access to formal education. Primary Practice Settings(s): Practical knowledge gained from the experiences of other case managers is not only free but also valuable. When we are exposed to the practical experiences and advice of seasoned case managers, we create an opportunity for knowledge sharing and reverse mentoring, which can result in leadership development (S. Powell, 2013). This article provides a historical glance into the evolution of today's case management practice, as well as provides salient lessons and advice from senior case managers who share practical tips and stories for tomorrow's case management leaders. Mentors share their career-long experiences in hospital case management, rehabilitation case management, pediatric case management, military case management, and hospice case management. Findings/Conclusions: Valuable lessons can be learned from reviewing case management's history that can be applied to improve current and future case management practice. Sources of information can be obtained from national organizations as well as from a review of the literature. Senior case managers who have dedicated their careers to case management can also be a vital resource, lending insights into pitfalls to avoid and best practices to implement in everyday practice. Implications for Case Management Practice: The case management mentors in this article have imparted the following key points to assist tomorrow's case management experts in maximizing their value:

A Targeted Discharge Planning for High-Risk Readmissions: Focus on Patients and Caregivers.

Racial and ethnic minorities with socioeconomic disadvantages are vulnerable to 30-day hospital readmissions. A 16-week quality improvement (QI) project aimed to decrease readmissions of the vulnerable patient populations through tailored discharge planning. The project evaluated the effectiveness of using a 25-item checklist to increase patients' and caregivers' health knowledge, skills, and willingness for self-care and decrease readmissions. The project took place in an inner-city teaching hospital in the Mid-Atlantic region. A casual comparative design compared readmissions of the before-intervention group (May 1-July 31, 2021) and the after-intervention group (August 1-October 31, 2021). A pre- and postintervention design evaluated the effectiveness of a 25-item checklist by analyzing the differences of Patient Activation Measure (PAM) pre- and postintervention survey scores and levels in the after-intervention group. Participants were General Medicine Unit patients 18 years or older who had Medicare Fee-for-Service, resided in 10 zip codes near the hospital, and were discharged home. Of 30 patients who received the intervention, one patient was readmitted compared with 11 readmissions from 58 patients who did not receive the intervention. The readmission rate was decreased from 19% to 4% during the 16-week project: 11 (19%) versus 1 (4%), p = .038. After receiving the intervention, patients' PAM scores were increased by 8.55, t(22) = 2.67, p < .014. Three patients had a lower postintervention survey level, whereas 12 patients obtained a higher postintervention survey level (p = .01). The increase in scores and levels supported that the intervention effectively improved patients' self-management knowledge, skill, and willingness for self-care. The QI project showed that the hospital could partner with patients at high risk for readmission and their caregivers. Accurate evaluation of patients' health knowledge, skills, and willingness for self-care was essential for sufficient discharge planning. Tailored use of the checklist improved patients' self-activation and functionally facilitated patients' and caregivers' care needs and capabilities. The checklist was statistically and clinically effective in decreasing 30-day hospital readmissions of vulnerable patient populations.

National Survey Data to Evaluate Case Management Services: A Systematic Review on Care Coordination Using the National Survey of Children With Special Health Care Needs.

Purpose of Study: The National Survey of Children with Special Health Care Needs (NS-CSHCN) is a publicly available resource that can be utilized to evaluate case management services such as care coordination. The authors sought to identify how researchers operationalize care coordination when utilizing this resource. Primary Practice Setting: National outpatient survey. Methodology and Sample: MEDLINE, PsycINFO, and CINAHL Complete were searched for studies that utilized the NS-CSHCN and report on outcomes of pediatric care coordination. Data from studies were extracted and results are descriptively reported. Results: The authors screened 4,577 citations and included 19 studies reporting on the impact of pediatric care coordination. Care coordination was defined differently and was sometimes captured as part of the medical home definition, or assessed using study-specific questions on coordinated services and satisfaction with communication from the medical team. Implications for Case Management Practice:

Text or Not to Text? A Narrative Review of Texting as a Case Management Intervention.

To review current literature on texting as a sustainable intervention of case management in the outpatient setting. Texting, as a case management intervention, provides the medically complex client with a pathway to achieve care plan goals. Texting increases adherence, communication, and self-management. It can increase client enrollment in disease management programs, while providing support, flexibility, convenience, cost savings, and increased participation. In current practice, such as management of the coronavirus (COVID-19), other pandemics, or natural/environmental disasters, texting is a solution-focused intervention that can deliver and retrieve real-time information to a medically complex population. It can link patients to resources and increase outreach, efficiency, quality, and coordination of care. Texting can promote adherence to appointments, increase medication compliance and disease management interventions, and provide motivational change messages. However, there are legal and regulatory concerns that carry potential consequences and implications that should be approached judiciously (Mellette, 2015). Texting is not one size fits all; it can cause HIPAA breeches, hinder communication with certain populations, confuse health messaging, and replace human communication, thereby reducing staffing in practice.

The Social Determinants of Mental Health: Assessment, Intervention, and Wholistic Health Equity: Part 2.

Purpose: The social determinants of mental health (SDoMH) continue to exert their fierce presence around the globe. The factors known to influence health outcomes equally impact mental health. A global mental health chasm has widened courtesy of COVID-19's intersection with every psychosocial aspect of functioning, inclusive of how people are born, live, learn, work, socialize, worship, and die. Racial, ethnic, and cultural inequities across the diversity, equity, and inclusion space have led to rising morbidity and mortality across every population. Part 2 of this article series is dedicated to assessment and intervention tools for the workforce. A key fifth or Quintile Aim of wholistic health equity is also presented to advance the industry's seminal quality compass, the Triple Aim, for the future. Learning Outcomes: After reading this article, learners will be able to: Finding/Conclusion: Access to quality wholistic health care encompasses pathophysiology, psychopathology, and psychosocial circumstances and remains a challenge across populations. Mental health, along with health disparities, has been fueled by systematic racism that has facilitated inadequate funding, poor reimbursement, decreased treatment options, and pervasive stigma across the cultural divide (e.g., race, ethnicity, gender, sexual orientation, familial status, disability, socioeconomic status). The SDoMH mandate a fresh lens by health and behavioral health professionals, and particularly case management, to ensure a more proactive and comprehensive approach to care. To achieve the successful outcomes mandated by this approach, the industry's quality compass, the Triple/Quadruple Aim, must be expanded to include a Quintile Aim of wholistic health equity. Implications for Case Management Practice: Case management's unique transdisciplinary composition has the workforce well positioned to effect grand change in population health perspectives. Wider attention to clinical and fiscal outcomes for health and mental health inequities mandates innovative approaches to patient care, which encompasses a wholistic health triad of pathophysiology, psychopathology, and psychosocial circumstances.

Creating a New Model of Care by Integrating Case Management Nurses in a Children's Hospital.

Nurse case managers (NCMs) have been identified as effective members of a care team in the development of effective and successful discharge plans. A pediatric hospital had an opportunity to change the model of case management (CM) in response to multiple initiatives. This article describes the process, barriers, and results of the integration of a new role into the care team. The role development and integration were done at a quaternary-level pediatric hospital. Introduction of the NCM role was accomplished through a multidisciplinary approach that employed continuous improvement, involvement of team and hospital leaders, and collaboration across multiple professions. The role was developed from one pilot to the eventual positioning of nine NCMs. Introduction of the new program resulted in a shift from a reactive dyad model of social worker-utilization management nurse to a proactive triad model of NCM-social worker-utilization management nurse. Success was measured by a decrease in the number of denials and an increase in the overturn of the denials received. Other results included the innovation of several processes that streamlined discharge planning and contributed to patient/family satisfaction. Creation of a new nurse-led CM triad team can be accomplished through multidisciplinary support and a focus on continuous improvement. Further collaboration on discharge planning standards and CM is indicated. Additional research focused on the impact of nurse-led pediatric discharge planning as it relates to readmission reduction and appropriateness of level of care and length of stay is also needed.

The Social Determinants of Mental Health: Definitions, Distinctions, and Dimensions for Professional Case Management: Part 1.

Purpose: The social determinants of health are a well-established health care industry priority. Robust data associated with psychosocial circumstances for populations validate poor health outcomes. However, another domain begs for inclusion and industry attention. A mental health chasm has emerged amid a post-COVID-19 landscape fraught with escalating health disparities, morbidity, and mortality. Themes of trauma, diversity, equity, and inclusion are major organizational imperatives. As a result, an expanded focus on the social determinants of mental health (SDoMH) mandates dedicated perspective. Part 1, of this 2 article series, on the SDoMH will provide distinct understanding of relevant industry terminology, historical drivers, and macro factors that influence mental health, along with health disparities. In addition, this article will set the foundation to advance the industry's quality compass, the Triple/Quadruple Aim. Learning Outcomes: After reading this article, learners will be able to: define the social determinants of mental health (SDoMH);distinguish them from the social determinants of health (SDoH);explore foundational concepts related to the SDoMH;understand upstream drivers of the SDoMH; andpresent evidence that validates attention to the wholistic health triad. Finding/Conclusion: Access to quality wholistic health care encompasses pathophysiology, psychopathology, and psychosocial circumstances, and is a considerable challenge across populations. Mental health, along with health disparities, has been fueled by enduring systematic racism that has facilitated inadequate funding, poor reimbursement, decreased treatment options, and pervasive stigma across diverse patient populations (e.g., race, ethnicity, gender, sexual orientation, familial status, disability, socioeconomic status). These SDoMH mandate a critical fresh lens by case management to ensure the most proactive and comprehensive approach to care. To achieve the successful outcomes mandated by this approach, the industry's quality compass, the Triple/Quadruple Aim must be expanded to include a Quintile Aim of wholistic health equity. Implications for Case Management Practice: Case management's unique transdisciplinary composition has the workforce well positioned to effect grand change in population health perspectives. Wider attention to clinical and fiscal outcomes for health and mental health inequities mandates innovative approaches to patient care, which encompass a wholistic health triad of pathophysiology, psychopathology, and psychosocial circumstances.

Safety-Net Accountable Health Model Partnership Drives Inpatient Connection to Outpatient Social Services, Reducing Readmissions in a Population Experiencing Homelessness.

Purpose of Study: To evaluate whether screening for homelessness during hospitalization and deploying outpatient care managers (CMs) to the inpatient setting to rapidly connect patients to community social services reduce hospital readmissions. Primary Practice Setting: A large safety-net hospital in Minnesota. Methodology and Sample: A quality improvement pilot proactively engaged hospitalized adults experiencing homelessness and enrolled in the Hennepin Health Accountable Health Model (HH AHM). Patients were screened for homelessness using a novel housing indicator tool, and eligible patients were visited in the hospital by HH AHM community CMs. If patients chose to pursue offered services, they were added to the CM's caseload with whom they met while hospitalized. Outcomes were compared between those patients who engaged in community case management initiated in the hospital (intervention group) and those who declined services or were discharged prior to an inpatient CM visit (control group). Chi-square, Fisher's exact, independent-samples t test, and Mann–Whitney U tests were conducted, as appropriate. Results: Seventy-two patients were included in the intervention group and 61 patients were included in the control group. Both groups were primarily English-speaking, African/African American and Native American men in their early to mid-40s. In total, 5.6% and 18% of intervention and control patients were readmitted to the hospital within 30 days. Of note, claims data confirmed that no readmissions occurred at outside hospitals in the first 9 months of the program. Twelve (16.7%) intervention patients were housed over the course of the study period, 5 occurring in the first 6 weeks. Implications for Case Management Practice:

Health Literacy, Health Confidence, and Simulation: A Novel Approach to Patient Education to Reduce Readmissions.

Purpose/Objectives: The vision for this project was to create an inpatient education intervention to better prepare patients with chronic medical conditions for more effective self-management after discharge using a Skills Simulation Experience and focused one-on-one structured education format in a circuit-based intervention. As an interdisciplinary intervention, the health care team presents standardized education in a circuit training presentation to allow for one-on-one interaction with health care professionals, using multiple teaching/learning strategies, to assist the participant in acquiring or reinforcing skills needed to successfully self-manage his or her conditions postdischarge. Primary Practice Setting(s): West Suburban Medical Center (WSMC) is owned by Pipeline Health and is located on the west side of Chicago, IL. WSMC is a 118-year-old community-based teaching facility that has collaboration with a local Federally Qualified Health Center, providing clinic space on-site as well as clinical rotations for OB/GYN. WSMC serves 2 very diverse neighborhoods, Oak Park, IL, home of Frank Lloyd Wright and Ernest Hemingway, and the Austin neighborhood of Chicago, which ranks 11th out of the 77 Chicago communities in violent crime. Findings/Conclusions: Data collected included the following: Implications for Case Management Practice:

Case Management on the Front Lines of COVID-19: The Importance of the Individualized Care Plan Across Care Settings.

Since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the disease known as COVID-19, case management has emerged as a critical intervention in the treatment of cases, particularly for patients with severe symptoms and medical complications. In addition, case managers have been on the front lines of the response across the health care spectrum to reduce risks of contagion, including among health care workers. The purpose of this article is to discuss the case management response, highlighting the importance of individual care plans to provide access to the right care and treatment at the right time to address both the consequences of the disease and patient comorbidities. The COVID-19 response spans the full continuum of health and human services, including acute care, subacute care, workers' compensation (especially catastrophic case management), home health, primary care, and community-based care. From the earliest days of the pandemic, case managers have assumed an important role on the front lines of the medical response to COVID-19, ensuring that procedures are in place for managing a range of patients: those who were symptomatic but able to self-isolate and care for themselves at home; those who had serious symptoms and needed to be hospitalized; and those who were asymptomatic and needed to be educated about the importance of self-isolating. Across the care spectrum, individualized responses to the clinical and psychosocial needs of patients with COVID-19 in acute care, subacute care, home health, and other outpatient settings have been guided by the well-established case management process of screening, assessing, planning, implementing, following up, transitioning, and evaluating. In addition, professional case managers are guided by values such as advocacy, ensuring access to the right care and treatment at the right time; autonomy, respecting the right to self-determination; and justice, promoting fairness and equity in access to resources and treatment. The value of justice also addresses the sobering reality that people from racial and ethnic minority groups are at an increased risk of getting sick and dying from COVID-19. Going forward, case management will continue to play a major role in supporting patients with COVID-19, in both inpatient and outpatient settings, with telephonic follow-up and greater use of telehealth.

Acute Care Management During a Pandemic.

During the global pandemic of Covid-19, the hospital setting transitional care management was challenged by the complexities of the rapidly changing health care environment, requiring the implementation of an innovative approach to hospital discharge planning. The purpose of this article is to review the experiences of an integrated urban health system, exploring the strategic tactics to ensure effective communication between team members, patient and family engagement in discharge planning, establishing and maintaining trust, connecting patients to appropriate next level of care services, and providing transitional care management support. The Covid-19 pandemic response stimulated the rapid transformation of the acute care management model amidst the tremendous challenge of meeting the discharge planning needs of the hospitalized population in one large, urban, integrated health care system. Patients transitioning to the community setting following discharge are vulnerable and at risk for adverse sequelae, and transitional care management that does not end when the patient leaves the hospital setting is integral to promoting positive patient outcomes (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). The care management approach during the pandemic in one health care system precipitously shifted to an entirely virtual, remote model, and the team continued to provide transitional care support for hospitalized patients to avoid the common pitfalls that are associated with unfavorable outcomes. The insights gleaned from one health system's experiences during the pandemic are transferable to other facets of care management in routine circumstances, with emphasis on the avoidance of the common care management snares that lead to less than optimal patient outcomes. The development and implementation of multifaceted interventions, with the goals of supporting health-promoting behavior changes and self-care capacity for at risk populations, are relevant in the current health care environment.

Community and Case Management Interventions to Address Social Determinants of Health in Infectious Disease.

Professional case managers are responsible to conduct education, counseling, and other interventions that address the unique needs and gaps of the patients and families they serve. Social determinants of health (SDH) can impact barriers to patient care and outcomes that may go undetected among underserved populations without reliable data. This article describes an implementation science study using patient and provider-informed data and designed interventions to mitigate barriers in SDH related to hepatitis B virus (HBV). Case managers and other health care team members in community health clinics examined discordances in their own patients' and providers' beliefs about patients' barriers to HBV care. Data were then used to help identify and engage unique strategies in education, counseling, and clinic outreach to improve outcomes in HBV and lessen barriers to care among at-risk minority populations. Findings from data and information conducted among the clinic patients and health care team members revealed many important barriers in key aspects of SDH occurring in each clinic. As a result, case managers and other health care team members were able to examine distinct differences in what they predicted their patients would say versus what patients actually answered about SDH aspects of their care experiences, including barriers in access to care, health monitoring, and treatment of HBV. The study and data results have implications for case management practice that may also be applied to other infectious diseases. Implications include patient and community outreach strategies to improve access to care; resource management techniques to improve referrals and disease monitoring; and ongoing and improved education and counseling to change behaviors associated with infectious disease prevention, screening, and linkage to care.

Death and Grieving for Family Caregivers of Loved Ones With Life-Limiting Illnesses in the Era of COVID-19: Considerations for Case Managers.

Purpose: Family caregivers of a loved one with a life-limiting or terminal illness are often overwhelmed by, and underprepared for, their responsibilities. They often need help from family members and friends to provide comprehensive care. When death occurs, funerals and other death-related rituals bring family and communities together to honor the life and mourn the death of a loved one and provide needed support to family and caregivers. These collective rituals are often deeply rooted in culturally-bound values and can facilitate grief and help make sense about loss. Rituals act as bridge-building activities that allow people to organize and appraise emotions, information, and actions after a loss. With the emergence of the coronavirus disease-2019 (COVID-19) pandemic and the recommended restrictions to reduce infection and transmission, family members and caregivers are often faced with weighing options for honored rituals to help them grieve. Grieving during the pandemic has become disorganized. The purpose of this article is to provide case managers and other clinical staff with recommendations on guiding caregivers/families through safety precautions when a loved one dies either because of a life-limiting illness or from COVID-19 during the pandemic using guidelines from the Centers for Disease Control and Prevention (CDC). The authors also present information about complicated grief and ways to support coping with death and suggest safe alternatives to traditional death-related rituals and funerals in a COVID-19 era. Primary Practice Setting(s): Primary practice settings include home health care, hospice, hospital discharge planning, case management, and primary care. Findings/Conclusions: Precautions necessary in a COVID-19 era may add anxiety and stress to an already difficult situation of caring for loved ones at end-of-life and grieving with their loss. Utilization of CDC guidelines lessens the risk of infection while honoring loved ones' wishes and cultural traditions surrounding death and burial. Recognition of social and spiritual connections that comfort mourners must also be considered. Implications for Case Management Practice:

Work-Sampling Study of an Innovative Care Coordination Program Aimed at Children With Chronic Health Conditions.

To estimate time allocation and labor cost for care coordinators (CCs), community health workers (CHWs), and mental health workers (MHWs) to conduct care coordination tasks in a pediatric care coordination program. A public tertiary academic medical center in Chicago, IL. A work-sampling study was conducted using a text message-based survey on 5 CCs, 20 CHWs, and 4 MHWs who volunteered to participate. Workers were randomly sampled within working hours to collect information on who was the subject of interaction and what service was being delivered over a 6-month period. Time allocation of workers to different subjects and services was summarized using descriptive statistics. Care coordinators allocated 41% of their time to managing CHW teams. Community health workers allocated 37% of time providing services directly to children and 26% to the parent/caregiver. Mental health workers allocated 16% of time providing services to children and 29% to the parent/caregiver. The care coordination program serviced 5,965 patients, with a total annual labor cost of $1,455,353. Community health workers spent the majority of time working with patients and their families to conduct assessments. Mental health workers primarily addressed children's needs through their caregivers. Care coordinators primarily supported CHWs in coordinating care. Results may be used to inform development of such programs by determining services most often utilized, and labor cost may be used to inform program implementation and reimbursement.

Serious Illness Conversations: A Case Management Quality Improvement Project.

The purpose of this project was to develop, implement, and evaluate an educational program and a serious illness (SI) protocol for a case management team of nurses and social workers to achieve the following: (1) utilize an SI protocol to identify patients with SI; (2) utilize a Serious Illness Structured Communication Guide to elicit these patients' goals and preferences for SI care; and (3) document in the electronic medical record the patients' elicited values and goals using a structured SI documentation template. Seventeen nurse and 3 social work case managers in an Accountable Care Organization (ACO) in a large health system in a western suburb of Chicago participated in this project. The practice setting was the primary care clinics associated with the health system. Patients eligible for the project met the SI criteria and were part of the organization's ACO or Bundle Payment for Care Improvement program. Twenty members of the case management staff participated in a 4-hr face-to-face educational program, based in part on review of best practices related to SI care and communication. Participants completed a pre- and posttest survey of knowledge; self-rated their confidence in conducting SI conversations; and evaluated the educational program. Participants then engaged in the established protocol inclusive of the following: (1) identify patients appropriate for an SI conversation; (2) initiate the SI conversation; and (3) document components of the SI in the electronic medical record. Educational Program: Ninety-five percent of the RN and SW case managers reported that that the educational module objectives were met to a moderate or great extent. One hundred percent of the participants reported that the format to deliver the program was effective, the content of the program was directly relevant to their clinical practice, and they would change their practice because of learning/understanding the content in the program. Educational program pretest scores ranged from 46.2% to 84.6%, with posttest scores ranging from 69.2% to 100%. A paired-samples t test demonstrated a statistically significant increase in posttest scores. Baseline confidence scores ranged from 1 to 4, with postproject confidence scores ranging from 2 to 4. A paired-samples t test demonstrated a statistically significant increase in confidence.Serious Illness Protocol: The case managers correctly identified 92% of patients who met the established SI identification criteria for this project. In 91.8% of cases, the case managers conducted an SI conversation in adherence to the protocol. In 76% of the cases, documentation about the SI conversation was completed in accordance with the protocol. .

The Evolving Role of the Professional Case Manager: A National Study From the Commission for Case Manager Certification: Part 2.

The purpose of the national role and function study was to identify the essential activities and necessary knowledge areas for effective professional case management practice from the perspective of those directly involved. The study also aimed to inform the relevance and currency of the blueprint for the case management certification examination. The national study covered the diverse case management practices and/or work settings across the full continuum of health and human services and numerous professional disciplines. This cross-sectional descriptive study used the practice analysis method and online survey research design. It employed a purposive sample of 2,810 certified and not yet certified case managers who responded to an open participation link made available as an online survey. The final study sample supported the conduct of meaningful statistical analyses including multiple subgroup comparisons. The study identified the common activities (6 domains) and knowledge areas (5 domains) necessary for effective performance by professional case managers. Part I of this 2-part article series described the background of the participants and their perspectives of the practice and the knowledge applied by those responsible for the case manager's role. Part II, as shared in this article, reports on the factor/principal component analysis and how such activity informed the needed update of the test specifications for the Certified Case Manager (CCM) certification examination. The update reflects the continued evolution of the professional case management practice and ensures that the examination remains current and relevant. Of special note is the maturation of the case management practice; for example, greater emphasis on quality, safety, and outcomes; baccalaureate or higher education; and recognition of the value of certification. In addition, the 2019 role and function study has revealed that utilization review/management is evolving potentially as a function that is separate from that of the case manager. The study has identified the essential activities and knowledge areas of case management practice at both the micro and macro levels. These findings represent the substantive evidence of practice, keeping the CCM credentialing examination evidence-based and maintaining its validity for evaluating the competency of professional case managers. They have also documented the evolution of the practice over the past 5 years. Moreover, the findings may inform the development of programs and curricula for the training and advancement of case managers. The study instrument also is beneficial for use in further research into professional case management practice.

Essential Case Management Practices Amidst the Novel Coronavirus Disease 2019 (COVID-19) Crisis: Part 1: Tele-Case Management, Surge Capacity, Discharge Planning, and Transitions of Care.

Objectives:This is the first of a 2-part article that discusses essential case management practices and strategies amidst the novel coronavirus disease 2019 (COVID-19). The series showcases the potential professional case managers have in support of managing during a crisis such as this global pandemic. Part I discusses reenvisioned roles and responsibilities of case managers and leaders known to address patients' needs during a crisis, with a special focus on telehealth, tele-case management, surge capacity, redeployment, discharge planning, and transitions of care.Primary Practice Settings:Applicable to the various case management practice settings across the continuum of health and human services, especially acute care.Findings Conclusions:The COVID-19 global pandemic crisis has brought an unprecedented challenge to professional case managers and health care professionals. It also has provided opportunities for innovation and partnerships within and across health care organizations and the various care settings where patients/support systems access necessary services. Most importantly, it created a renewed interest in telehealth and facilitated a wider adoption of such approach to care delivery than ever before. This pandemic has also increased the use of nontraditional sites of care, most importantly those that operate virtually on electronic networks and health information system technologies such as remote visits, e-visits, virtual care, and tele-monitoring. Undoubtedly, these have provided new opportunities for tele-case management services and roles for professional case managers in the virtual world of health and human service delivery.Implications for Case Management Practice:Professional case managers are integral members of interprofessional health care teams. Their roles are even more necessary during a global pandemic such as COVID-19. The practice of case management will forever change—for the better. The experience of this crisis in health care has brought about ever-lasting implications for case management professionals. It has raised awareness to sites of care never were as popular before, resulting in an increased need and recognition for tele-case management practice and virtual case managers. It has also forced partnerships and collaborations among the diverse contexts of health care organizations (public, private, or both) and other industries, regardless of whether directly involved in the delivery of care or having a support service role. These new and innovative approaches in the provision of care and case management services will without a doubt become routine expectations beyond the current pandemic period. Of special note are the enhanced roles of case managers in discharge planning and transitions of care.

Essential Case Management Practices Amidst the Novel Coronavirus Disease 2019 (COVID-19) Crisis: Part 2: End-of-Life Care, Workers' Compensation Case Management, Legal and Ethical Obligations, Remote Practice, and Resilience.

Objectives:This is the second of a 2-part article that discusses essential case management practices and strategies amidst the novel coronavirus disease 2019 (COVID-19). The series showcases the potential professional case managers have in support of managing during a crisis such as a global pandemic. Part II continues to describe reenvisioned roles and responsibilities of case managers and their leaders to meet the needs of patients/support systems during the crisis. It focuses on the increased need for end-of-life care, impact on workers' compensation case management practice, and the self-care needs of the professional case manager.Primary Practice Settings:Applicable to the various case management practice settings across the continuum of health and human services, with special focus on acute care.Findings/ConclusionsThe COVID-19 global pandemic has resulted in a crisis case managers and other health care professionals never faced something like it before. At the same time, it has provided opportunities for innovation and creativity including use of digital and telecommunication technology in new ways to ensure the continued delivery of health and human services to those who need them regardless of location. It has also resulted in the development of necessary and impactful partnerships within and across different health care organizations and diverse professional disciplines. Most importantly, this pandemic has required special attention to the increased need of patients for timely palliative and end-of-life care. In addition, it has prompted a focus on the safety, health, and well-being of case managers and other health care professionals, resulting in expanded workers' compensation case management practice coupled with the need for self-care and resilience.Implications for Case Management Practice:Professional case managers are integral members of interprofessional health care teams. Their roles and responsibilities are even more necessary during the uncertainty of a global pandemic such as COVID-19. So far, the experience of this crisis has resulted in a deliberate need to ensure the safety of both, those who are the recipients of health care services and those who are responsible for the provision of care. Self-care and resilience of health care professionals and case managers, especially due to the complex dynamics of the COVID-19 pandemic, have advanced a desirable and necessary view of remote/virtual practice and as a strategy for enhancing the person's health and well-being. This pandemic has forced the development of impactful partnerships and collaborations among the diverse contexts of health care organizations and support service providers. These contexts of care delivery have also emphasized the necessary legal and ethical practice of case managers and the other involved parties. Experts agree that the innovative care delivery methods practiced during the pandemic will undoubtedly remain as desirable beyond the current crisis period.

End of Life Care's Ongoing Evolution.

PRIMARY PRACTICE SETTINGS:: Applicable to all settings across the transitions of care where case management practice occurs. Continuing shifts in society's cultural landscape, ongoing emphasis on value versus volume, and other industry fiscal imperatives continue to evoke an evolution in end-of-life care. The attainment of successful outcomes by professional case managers with those populations will be dependent on awareness and comprehension of regulations, legislation, and reimbursement; the influences of ongoing industry trends; availability of emerging resources; and ongoing technological advances. Ethical excellence remains at the core of case management across the interprofessional workforce and the transitions of care. The professional case management workforce is tasked to effectively intervene across diverse client populations, with their caregivers and support systems. This action spans every life stage and illness course. With end-of-life care treatment and processes continuing to receive prime industry attention, case managers must be knowledgeable of the moving parts of this arena. Awareness of the ethical edges of each professional's sandbox is essential to quality-driven case management practice.