Skills for Successful
   Case Management

Professional nurses, case managers, and social workers have been key advocates in the provision of quality healthcare. Their broad skills and training allow them to assess patients' needs and to work well with families and other members of the healthcare team. Negotiating, collaborating, communicating, team building, precepting, educating, and consulting are the basis of what a successful case manager brings to the care setting each day.
     
The application of the nursing and case management processes is concerned with the whole person and the full range of patient needs. This clearly leads to comprehensive and consistent care. Much has been written about the nursing process and its unique qualities. Yura and Walsh (1983) noted the following, which is still applicable today: In contrast to the goals of the other members of the health profession, the nurse is involved with human needs that affect the total person rather than one aspect, one problem, or a limited segment of need fulfillment.
     
Case management is no different in its approach to successful coordination of patient care than that of nursing or those applied by other professionals. The role of the case manager , by its definition as outlined in the Case Management Society of America's Standards of Practice for Case Management (2002), upholds and expounds on the nursing process. Case management is a collaborative process used to assess, plan, implement, coordinate, monitor, and evaluate options and services to meet individuals' health needs through communication and available resources to promote quality, cost-effective outcomes.
     
The case manager's expertise is the vital link between the individual, the provider, the payer, and the community. Successful outcomes cannot be achieved without using all of the specialized skills and knowledge applied through the case management process. It must be emphasized that the skills necessary to be a successful case manager are not possessed by everyone. Case managers need to be clinically astute and competent in areas of practice. It is important for case managers to be skilled in the application of the case management process and to acquire the assessment skills that make them better able to identify the patient's actual and potential health problems. This allows them to implement the required interventions to successfully resolve these problems and to evaluate the outcomes of care and responses to treatments (Bower, 1992).
     
Not all nurses acquire the professional credentials, education, and expertise in the application of the nursing process to succeed as a case manager. Case managers are notoriously consummate organizers, paid to be in control of what many would regard as sheer chaos. Does their skill for organization derive from a compulsive personality, years of experience, mastering the nursing process, or a balanced blend of all of these components? One would believe the latter to be true. As long as there is a subtle balance of the dynamics a case manager possesses, there will be a positive effect.
     
How does this overview translate and apply to the required skills necessary for today's successful case managers? The section that follows categorizes and details each function and skill that becomes a critical element when providing the services of an effective case manager (Box 1).

NURSING PROCESS
Assessment
Assessment is an ongoing and continuous process occurring with all patient–case manager interactions. It is during the assessment phase that the case manager seeks a better understanding of the patient, the family dynamics, and the healthcare beliefs and/or myths. An assessment generally involves three phases, which at times seem inseparable: gathering data, evaluating data, and determining an appropriate nursing diagnosis. Case managers use a multifaceted subgroup of skills (Rorden and Taft, 1990) to assess a patient's needs accurately: As an assessor, the case manager must obtain relevant data through skillful investigation. All of the information related to the current plan must be evaluated with a critical eye to objectively identify trends, set and reset realistic goals, and seek viable alternatives as necessary.
     
Part of being a successful assessor is to find a delicate health balance for each patient. Needs and demands are balanced by strengths and resources. When there is a balance between these factors, there can be positive movement. When a patient is in acute distress, patient needs may be only the obvious; however, if a health balance is to occur or to be restored, the case manager must uncover factors that influence the relationships between needs, strengths, and resources. A representation of this health balance model is shown in Figure 1 (Rorden and Taft, 1990). Case Study 1 presents an example of the use of the health balance model during the assessment of a patient.
     
A vital case management skill is the ability to recognize a patient's health problems and formulate diagnoses based on the subjective and objective data collected during the assessment. The diagnoses express the case manager's judgment of the patient's clinical condition, functional abilities, responses to treatments, healthcare needs, psychosocial support, financial status, and postdischarge needs.

Planning
Planning is the next step in managing the patient's care. This is accomplished by planning the treatment modalities and interventions necessary for meeting the needs of patients and families. During the planning phase the case manager, in collaboration with the other members of the healthcare team, determines the goals of treatment and the projected length of stay and, immediately on admission, initiates the transitional plan of care. The determination of goals is vitally important because it provides a clear timeframe for accomplishing the care activities needed (O'Malley, 1988). Case managers must identify immediate short- and long-term needs, as well as where and how these needs will be met.
     
Planning is initiated as the patient is admitted or before admission to any healthcare setting. The case manager's clinical expertise is quickly tapped into when establishing whether the treatment plan and interventions are appropriate. Data are assimilated, diagnoses are established, and a multidisciplinary plan of care begins to unfold.
     
Throughout the acute hospital, subacute, home care, or long-term care stay, the case manager monitors and reevaluates the plan for accuracy as the patient's condition changes. As a planner, the case manager identifies a treatment plan while remaining cognizant of the patient outcomes and minimization of payer liability. The case manager must include the patient and family in decision making and consider the patient's goals as an integral part of the care plan. Alternate plans must always be incorporated in anticipation of sudden shifts in the treatment process or in response to treatments yielding complications. Case Study 2 illustrates the principles of successful planning.

Implementation and Coordination
Implementation and coordination involve building the plan, determining the goals of patient care, and deciding what needs to be accomplished to make a viable and realistic plan move to completion. The aim of the case manager at this point is to give the patient and family the knowledge, attitudes, and skills necessary for the implementation of the established plan. Through communication, collaboration, and teaching, the case manager works with the multidisciplinary team to motivate the patient to succeed in fulfilling the plan of care determined by all of the participants. Abraham Maslow (1970), in his theory of the hierarchy of needs, suggested that everyone seeks fulfillment of general needs and that these needs motivate behavior. At a time of high stress or ill health, people seek to fulfill more basic needs, such as survival and safety. The higher needs of self and creativity do not seem as much a priority at this time (Maslow, 1970).
     
The case manager needs to be aware of this theory of motivation when trying to elicit decisions about discharge planning or future goals for a patient. The patient and family must first reach a level of awareness that enables them to focus on the goals of the care plan. They must then reach a level of understanding at which they learn in greater depth what the patient's needs and the available options are, the likely consequences of these options, and what aspects of self-care need to be learned. It is at this juncture that motivation will take place and the implementation of the plan will come to fruition.
     
As the patient nears discharge, the case manager can take three steps to improve the chances of effective implementation of the plan: clarifying the transfer of responsibilities of care, reviewing the plan to ensure that nothing has been overlooked, and making last-minute alterations and arrangements for the immediate discharge period. Following these steps will confirm the plan for continuing care (Case Manager's Tip 1). Case Study 3 presents an example of what can happen to implementation if a step-by-step approach of assessment, diagnosis, planning, and coordination does not take place.

Evaluation
The final step in the nursing process, evaluation, is designed to measure the patient's response to a formulated plan and at the same time to ensure the appropriateness of the care plan and the quality of the services and products being offered to the patient.
     
To achieve successful evaluation and outcomes, the case manager must routinely assess and reassess the patient's status and progress toward reaching the goals set forth in the plan of care. If the situation is at a halt or regressing rather than moving forward, the case manager must then make appropriate adjustments and alter the plan accordingly.
     
The following important questions must be asked as the evaluation proceeds: These questions will help the case manager to determine if the overall discharge plan for a particular patient was effective and will assist with quality improvement efforts for future patients. This information also is valuable when evaluating the facility's total case management program. Throughout the evaluation process, all participants in the interdisciplinary team will identify system, process, clinician, patient, and family variances and trend them. These trends will be further analyzed in continuous quality improvement (CQI) teams to improve, fine-tune, revamp, and reorganize the processes of care delivery.
     
The case manager must use many skills and functions of leadership to effectively master the nursing process (Case Manager's Tip 2). A more specific and comprehensive breakdown of these skills will add to the role dimensions of the case manager.

LEADERSHIP SKILLS AND FUNCTIONS

Because case managers function as problem solvers, resource people, and members of the multidisciplinary healthcare team, they should be highly skilled in various leadership qualities. Nursing case managers must be adept at negotiating and contracting and capable of making sound decisions and resolving conflicts. To do this successfully, they should acquire critical thinking and problem-solving skills. Because of their managerial responsibilities, case managers must be involved in quality improvement efforts, speak publicly, and write for publication.

Advocacy and Facilitation of Care Activities
The case manager's work as an advocate (Case Manager's Tip 3) for the patient is one of the most critical elements of the role. The patient-case manager relationship is built on the ability of the case manager to be trusted; to foster mutual respect between himself or herself and the patient; and to establish a rapport that facilitates communication among the family, caregivers, payers, and other healthcare team members. As case managers gain clear understanding of the patient's needs, care desires, and goals, they communicate this understanding effectively to the members of the healthcare team. They also impact the course of treatment to effect an earlier discharge, negotiate better fees for medical supplies or equipment, or arrange for more efficient home care services.
     
As a facilitator, the case manager can be a catalyst for change by empowering the patient or family members to seek solutions throughout the acute care phase and beyond the hospital setting. The case manager is always on the lookout for quality improvement that could result in potential cost savings or possibly prolong the healthcare benefits of an individual.
     
The patient's best interests are always the focal point for the case manager's advocacy and care facilitation efforts, whether for needed funding, treatment options, appropriate and timely home health services, or reassessment and evaluation of goals. Case managers are concerned with every detail, sifting through the complex array of paths that can easily lead to confusion for any patient. Case managers advocate for their patients/ families in three main ways. These are as follows:      
  1. Defending patients' rights to treatments and options
  2. Helping patients to discuss their needs and preferences and to make informed choices that are consistent with their values and beliefs
  3. Respecting and honoring patients' values and beliefs and helping them maintain their dignity (Powell and Ignatavicius, 2001)
 Clinical Reasoning and Critical Thinking
In the practice of case management, patient, family, and healthcare provider problems continually arise. Therefore it is important that case managers are able to solve these problems. The ability of case managers to provide safe, efficient, and competent case management services depends heavily on their skills in problem solving, clinical reasoning, and critical thinking. These skills have one thing in common: they all entail the generation of possible solutions to problems, issues, or concerns regarding patient care delivery and options. Case managers use their clinical knowledge and expertise and their leadership skills for this purpose. They capitalize on their role as informal leaders of the healthcare team and facilitators of patient care delivery to solve the problems that may arise.
     
Case managers are constantly making decisions. They decide what observations should be made in encountered situations, derive meaning from the observations made and data collected, and decide on the actions/interventions to be taken to care for the patient or resolve the situation. The overall goal is the delivery of optimal, cost-effective, quality care.
     
Case managers use a framework for decision making and problem solving (Figure 2) that bridges the present and the future. They assess the patient's and family's current state and, based on this assessment, they envision the future state by deciding on the goals and expected outcomes of the treatments. They then implement an action plan to bring the patient and family to the desired future state. This framework enhances an outcomes-based approach to the delivery of case management services. The plan is usually interdisciplinary in nature and implemented only after approval by the healthcare team and consent and agreement by the patient and family. Understanding that the action plan may not always result in a resolution of the patient's and family's problems, issues, and concerns, case managers engage in constant reassessment, monitoring, evaluation, and revising of the plan until the desired outcomes (i.e., the future state) are achieved. Case managers complete these activities using a testing technique applied to examining the appropriateness of the action plan and the relevance of its outcomes.
     
The case manager's skills in decision making and clinical reasoning and judgment must always help the patient to work through the confusion he or she faces in the complex healthcare environment. Case managers operate by answering questions pertinent to the development of the plan of care, actual delivery of care, and evaluation of the discharge plan, such as those following. These questions are examples of how case managers engage in evaluating the case management action plan using the problem-solving framework shared in Figure 2.      
Answers to these questions influence the type of care a patient will receive and how it will be accomplished to ensure the best possible outcome for a patient in the most cost-effective manner. Case managers who are able to apply critical thinking and clinical reasoning skills in the decision-making process ensure appropriate, effective, and efficient care delivery. This makes certain that the patient and family will receive the necessary support, potential obstacles to the treatment plan will be avoided, the potential for readmission will decrease, the educational component of care will be reinforced, and a positive outcome and promotion of health will take place.

Negotiation
Negotiation is a skill that is not primarily taught in nursing or social work education programs. To be a successful negotiator, a case manager must be a good time manager. Along with managing their own time, case managers must learn to determine what work others can and should do in assessing a patient's needs when preparing a patient's plan of care. This understanding allows them to negotiate more effectively.
     
Negotiation in case management is an everyday occurrence. It is a skill used with payers and providers, with vendors for durable medical equipment, with the patient and family/caregiver, and even with physicians reluctant to opt for a home care discharge plan or placement in a long-term care facility. The purpose of negotiation is to reach an agreement. Fair negotiation requires trust, rapport, and complete honesty with regard to a patient's care needs. Successful negotiation (Case Manager's Tip 4) is achieved by being well prepared to present the facts clearly and succinctly. To know if you have negotiated your case well, you must be a good listener who tunes in to verbal and nonverbal cues; otherwise, windows of opportunity could be missed. On the financial side of the equation, we know all too well that healthcare environments are committed to doing more with less and at a lower cost. Financial prowess on the part of the case manager is a must in these times of cost containment. Case managers must work with financial support personnel and help them keep abreast of a patient's insurance health benfit plan, no-fault coverage, or a patient's lack of finances that could lead to Medicaid eligibility.
     
According to Umiker (1996), negotiation may take three forms:
  1. Power play: Assumes that the stronger party will win. The power play process is a form of combat in which one side makes an unfair offer and expects the other side to counter with an equally unfair demand.
  2. Taking positions: Assumes a win-lose outcome. This is a form of haggling wherein each side adopts a fixed position and assumes an inflexible stand.
  3. Collaboration: Assumes a problem-solving approach. This form of negotiation results in a win-win situation wherein each side desires to end up with a good deal while preserving the integrity of the other.
 Collaboration is the most desired approach for negotiation by case managers. It is the only of the three forms of negotiation that allows all parties involved to win and to be pleased with the outcome. It also makes the process more efficient, positive, and amicable. The other two forms must be avoided because they tend to be unproductive and divisive and to work against building teams and effective relationships. The power play approach is usually aggressive, intimidating, and condescending; in the taking positions (haggling) approach, rather than solving problems, the process of negotiation becomes a contest of wills (Umiker, 1996).

Utilization Review and Management
Case management plans can be useful tools when determining the allocated resources for a particular diagnosis. Variance analysis or comorbid conditions can help a case manager anticipate extra costs, such as the need for longer hospitalizations, expensive antibiotic treatment, or pain management therapy.
     
Working alongside the hospital's controller to review the expenses incurred for various diagnoses will serve as a checks-and-balances system of appropriate allocation of funds. The case manager has a key role in being able to communicate the overutilization of laboratory tests or repetitive diagnostics or the underutilization of less-expensive antibiotics. Thus the case manager can have a major positive impact on the ability of an institution to provide the same quality of care that it is accustomed to while being more cost-efficient in the process.
     
Another way in which case managers affect the financial balance of an acute care setting while monitoring quality is through utilization review and management (see Section 3, Chapter 1). Participation on a hospital length-of-stay committee is one way to monitor utilization. The healthcare team can then be alerted to an inappropriate admission, an unusual length of stay for a given patient, a planned premature discharge with no clear discharge plan and with potential readmission risk, or inappropriate use of resources. It is case managers who are charged with monitoring these potential financial drains on the healthcare organization. It is their high-quality efficiency that provides the organization with a safety gatekeeping mechanism to avoid potential utilization problems. Knowledge of utilization review and management is also effective in subacute, home care, and insurance arenas to justify or nullify care requested.
     
In this ever-shrinking resource environment, it becomes more and more prudent for the case manager to be an instrumental participant in payer contract negotiation, on resource management teams and clinical pathway development committees, and in any groups designed to promote quality care at less cost but with high efficiency. It is the driving force behind every great case manager to maximize patient outcomes and quality of care while being ever cognizant of the dwindling resources to provide that care.

Patient and Family Education
One of the last but certainly not least leadership skills is that of educator. This is a large responsibility within the case manager's role because it covers a broad scope of functions. Being a facilitator of both the patient and the staff is at times a monumental task that brings with it periods of extreme challenge. A good principle to follow is to begin with the end result in mind. First there is the mental picture of the outcome of your patient's plan of care; then you begin to formulate the blueprints and develop your construction plan to get the patient and family to the projected outcome. This idea can be conveyed through the use of the analogy of constructing a house. The blueprint for the house is meticulously designed before any physical creation of the house is begun. Without a developed blueprint, the physical creation will undoubtedly have expensive changes that could double the cost of the house. The case manager, much like the carpenter, must make sure that the blueprint (i.e., patient's plan of care) includes everything needed and that everything has been thought through (Covey, 1989).
     
Educating the patient and family is part of the blueprint for success. The clearer the understanding of the disease process and the course of the acute level of care, the better the plan will be. Of utmost importance is that the case manager considers educating the patient and family using language that is understood, with consideration for cultural diversity and healthcare beliefs. In our constant awareness of the pressure to reduce lengths of stay, education is sometimes elected to take a back seat. However, timely education is crucial, especially as patients experience shorter hospital stays. Placing education at the bottom of the priority list can have devastating effects on outcomes. For example, a family decides to take their loved one, who is dependent on a ventilator, home. All plans appear to be in place: the respiratory company has been arranged, the home is prepared, and the nursing visits are on standby. Everything seems to be ready, but a crucial element is missing. No one thought about the necessity to teach the family how to care for their family member at home, including expertise in ventilator function and resuscitative measures. Without this most important step of early education, the discharge plan runs the risk of failure, costly extra days in the hospital, or potential rehospitalization of the patient as a result of lack of knowledge on the part of family members or the inability to handle the patient's care.
     
Do the patient and family respond better to verbal or nonverbal communication, audio or video, written word or pictures, discussion or demonstration? It is the case manager who can impact the education process by serving as the resource for staff to develop or select supporting educational materials and define the best method of conveying the information (Case Manager's Tip 5). The case manager may also serve as a member of the patient teaching committee responsible for patient and family teaching materials or documentation tools such as the one shown in Figure 3.
     
Ensuring compliance with standards of patient and family teaching as outlined by regulatory and accreditation agencies is also a required facet of the case manager's role. Case managers are involved in nursing staff development by enhancing and disseminating new knowledge and skills. They act as mentors and preceptors of less senior staff. The knowledge of case management itself must also be conveyed across professional lines and levels of hierarchy. In addition, the community is in need of hearing and learning more about case management; that way, if a person is hospitalized or offered the option of home care, he or she will have an appropriate expectation of case management and how the case manager will be involved in the plan of care.

COMMUNICATION AND OTHER INTERPERSONAL SKILLS

Communication and other interpersonal skills are the lifeline that connects each individual in any walk of life and in any organization. As our technological world moves faster, quality communication becomes essential. Many would claim that communication is the core of leadership and decision making. Without a doubt, thorough communication is a core managerial function. Therefore as managers and leaders, case managers must master effective communication to be successful. Communication is the transfer of information, ideas, understanding, or feelings. Case management is working with and through others. Communication is necessary so that each person knows his or her role in the process of accomplishing goals.
      Dash et al (1996) define communication as follows: We take communication for granted, but in the case of quality job performance—as in the role of a case manager—it should not be treated lightly. A miscommunication or a barrier to effective communication could lead to expensive hardship for a hospital, payer, patient, or family. In fact, it is easier to miscommunicate than to communicate clearly. At any stage in the process of communication something can interfere with its effectiveness, clarity, or accuracy. This interference is called noise. Noise can be physical, such as a cardiac monitor beeping in a patient's ear; psychological, such as the fear of or anxiety as a result of being hospitalized; or anything else that keeps the message from getting from sender to receiver.
     
A communication model has at least four elements (Figure 4). The first element is the sender, as in the case manager, who transmits the communication message. The second element is the message, which includes the verbal (i.e., spoken or written) and nonverbal (i.e., facial expressions and body language). The third component, the receiver, is the person to whom the message is sent. If all goes well, the message received will be the intended message sent. The fourth component, the context, is the surroundings in which the communication takes place. The environment is identified by such factors as the patient's condition, cultural background, health beliefs, and values (Dash et al, 1996).
     
The channel one chooses is also a key to effective communication and must be individualized to the patient's readiness to learn and preferred method of communication (e.g., face-to-face communication, group meeting, or written information). In addition, the listener's receptivity must be established and maintained if quality communication is to take place.
     
Because barriers to communication are the pitfalls for any case manager to try to avoid, it is helpful to review some examples in depth.

Physical Interference
The first and most important step in improving communication is to make sure that your intended receiver receives the message. The sender (case manager) must take full responsibility for seeing that the physical barriers to communication are reduced. Case Study 4 provides an example of such a situation.

Psychological Noise
The root cause of this interference is distraction (thinking about something else). Accuracy is at stake here. Hunger, anger, depression, medication, and fear all have an impact on the way the receiver understands. Asking for feedback, providing feedback, and verifying the accuracy of the message helps identify the existence of a psychological barrier. See Case Study 5 for an example.

Information Processing Barriers
Our brains have the miraculous ability to take in enormous amounts of data but can only process consciously one thought at a time. If information is being sent too fast, the brain and therefore the receiver have trouble taking it in (Case Manager's Tip 6). Communication overload is a classic example of a processing barrier. During communication overload too much information is being sent, and the receiver cannot process it all. The receiver then becomes overwhelmed and shuts down. You have probably seen this occur numerous times. Picture yourself giving a patient instructions on how to test his or her blood sugar. You go on and on reciting the steps of pricking the finger, dabbing a drop of blood on the glucose test strip, and preparing the machinery to accept the strip for reading. When you suddenly try to make eye contact, what you see is a face staring back at you blankly. The patient is overwhelmed by your instruction, is overloaded, and has shut down.

Perceptual Barriers
Each individual brings a unique set of past experiences to communication. These experiences, good or bad, will influence how a person perceives the meaning of your communication. Perception is greatly influenced by our value system. We interpret everything we experience through mental images, and we tend to assume that the way we see things is the way that they really are and the way everyone else sees them.

Structural Barriers
There are aspects of organizational structure that can affect the quality of communication. These next barriers to communication, as those previously mentioned, can be applied not only to a case manager's patients but also to a case manager's peers, other members of the multidisciplinary team, payers, and upper administrative management.
     
The more people who are involved in a chain of communication, the greater the likelihood that message interruption can occur (Case Manager's Tip 7). You may remember the old game of "telephone" in which a message is whispered into the ear of one person after another. By the time the message reaches the last person it is substantially different from the initial message. Usually the important details such as times, dates, and names become confused.

Defensive Communication
Defensive communication can also be a barrier to the effective transmission of the message. This type of communication occurs when people attempt to protect themselves from a real or perceived threat. The threat could be related to the sender or receiver of the message, or it could be present in the message itself. Defensive communication tends to occur when there is a lack of trust—for example, when the receiver of the message is doubtful or suspicious of the sender's motives. Message-related defensive communication takes place when the message being sent contains challenging content or disregard for the receiver's values, beliefs, worth, or feelings (Lancaster and Lancaster, 1999).

Power
If communication must take place between various levels of authority or power, the differences in status can result in poor-quality communication. This is known as information processing or filtering. Overcoming the communication barrier imposed by status differences is mostly a matter of realizing that it can occur (Case Manager's Tip 8). There are generally two types of power:      
  1. Directive power, or power used to affect the behavior of others with the intent of satisfying personal needs
  2. Synergistic power, or power used to increase the energy and creativity of all participants with the intent of satisfying the needs of all participants
Knowing how and when to enforce power appropriately, along with having the components of a trusting relationship, will result in a shared sense of responsibility and better outcomes. Possessing a solid power base is crucial, and its appropriateness is essential. As an expert case manager, you must be willing to share expertise, issue directives, follow up on compliance, and attempt to influence as occasions arise (Bass, 1985). Case Study 6 provides an example.

Trust
Stress and lack of trust are additional structural barriers to communication. They both interfere with accurate, clear communication, and they both affect the ability to express needs and share information openly and honestly. Building rapport and a trusting relationship usually has the added bonus of reducing stress, thereby increasing the chances of accurate communication.
     
The following sections outline the four basic qualities a case manager should exhibit to initiate a patient-case manager or case manager–colleague relationship in which trust can be developed.

Warmth
This quality helps others to feel accepted. Nurses who are willing to extend themselves with openness rather than exhibit cold, expressionless, disapproving behavior will gain trust more quickly. Warmth reflects self-respect, self-acceptance, and genuine concern for others, and people respond to this type of behavior favorably.

Respect
Treat others as you would want to be treated; take into consideration personality, culture, opinions, customs, values, and beliefs. To respect another person does not necessarily mean that you must like that person; however, you must accept and value him or her. This becomes important to a case manager when a family's or patient's decisions regarding a discharge plan are not in full agreement with the case manager's recommendation. Keeping patients informed about their care gives them the feeling that they are respected as individuals, not just seen as a bed number or a disease entity.

Empathy
Helping people to feel understood means actively tuning into feelings and thoughts and letting go of stereotypes and prejudices. This is an essential ingredient in trusting relationships. You must really hear, without demanding that someone feel as you think they should in a given situation (Rorden and Taft, 1990).

Genuineness
This final component of verbal communication enhances the trust relationship. This quality allows people to feel that they are interacting with a real person who is interested in their well-being. Consistency is a facet of being genuine. If there is inconsistency between verbal and nonverbal behavior, communication will break down (e.g., the case manager who voices concern about a patient's situation but fails to make eye contact will surely be judged as "put on"). Keep in mind that people who are already stressed by their situation will be more astute to false behavior and inconsistent communication. Armed with the knowledge of the many barriers to communication and the ways in which to avoid or to minimize them, the case manager must now become versed in the communication channels that effectively transmit the message from sender to receiver.

COMMUNICATION PATHS

The path that a communication takes, whether it be formal or informal, has an effect on the communication itself (Rawlins, 1992). Formal communication takes two forms: downward and upward. Downward communication is communication about what to do, how to do it, and when it is to be completed. This communication usually takes place when delegating to subordinates. To delegate effectively, all of the aforementioned barriers should be avoided. An example of upward communication is when a case manager speaks with a chief financial officer (CFO) to request financial approval, as in the previously discussed scenario of flying a patient back to her home rather than incurring the cost of an extended hospital stay. The result is a more accurate managerial process, greater participation, and interactive control of the positive destiny of an organization.
     
Informal communication usually takes place between smaller groups, such as the case manager and the social worker. Managers in these two areas may get together after a more formal meeting to discuss a policy that may affect both of their departments. This type of communication must be based on mutual trust, or a more formal communication will need to follow.
     
In addition to becoming aware of typical barriers to effective communication and channels of communication, case managers can take additional steps to improve communication competency. How colleagues work together as a team can determine the success or failure of any work environment. Good relationships are fostered when colleagues respect each others' job duties.

Teams
There is a great difference between an effective team and a group of people who have been thrown together with no clear goals (Haase, 1992). There are generally 10 elements of an effective team. While reviewing these elements, think about the members of your organizational team, whether they be social workers, discharge planners, utilization reviewers, nurse managers, payers, or physicians. Rate the effectiveness of your team effort toward a productive case management program and better patient outcomes. You will begin to see that many if not all of the elements incorporate the communication and interpersonal skills discussed throughout this chapter (Haase, 1992):      
  1. Team members communicate openly and honestly. They listen with understanding.
  2. Team members have common goals and a clear idea of the team's mission.
  3. Team members support each other. They have assigned duties and are not engaged in turf wars.
  4. Team members take pride in their group's efforts and results.
  5. Team members help make decisions on important issues but when necessary are willing to look for guidance for final decisions.
  6. Team members feel comfortable expressing ideas, opinions, and disagreements.
  7. Team members are encouraged to make the development of new skills a way of life.
  8. Team members are encouraged to use their unique skills and talents.
  9. Team members realize that conflict is normal and that working out differences can lead to new points of view and creativity.
  10. Team members value appropriate humor. Having fun increases openness, enthusiasm, and energy.
 These ten elements involve potential attitude adjustment, releasing of power, respect, compromise, and conflict resolution.

Conflict
Administrative pressures for cost control and consumer demands for safe and quality care influence case managers in their daily decision-making activities. Now more than ever it is necessary for case managers to work collaboratively with members of the interdisciplinary team to meet the pressures and demands of healthcare delivery. Case managers must keep in mind that conflict is inevitable and that it is not a negative occurrence as it was once believed to be. Conflict is merely individuals or groups experiencing differences in views, goals, facts, or values that place them at opposite poles. It usually involves areas of differing expertise, practice, or authority.
     
In most situations conflict falls into one of three categories: perceived conflict, the thought that conditions exist between groups that cause the conflict; felt conflict, when the conflict evokes feelings of threat, hostility, fear, or mistrust; and expressed conflict, which takes the form of debate, assertion, competition, or problem solving. There are five different strategies for resolving conflicts (Box 2). However, the most often used tactic to resolve conflict is the collaborative win/win resolution. Groups usually identify solutions that will allow each to maintain their goals and ultimately create a resolution that they can live with (Kirsch, 1988).
     
The ability to successfully manage conflict is an important skill for the case manager to master. It can help the case manager to increase the total benefits of the group efforts by becoming more innovative and creative, with the overall outcome of increasing productivity and achieving goals (Case Manager's Tip 9).
     
One member of the multidisciplinary team, the physician, is a vital communication source. If there are conflicts or obstacles to the case manager–physician communication, then quality patient care will suffer. Professional and up-front communication regarding the case manager's role is a good place to start in building an effective team among the disciplines. Case managers must initiate positive dialogue with physicians and address the stereotypes and stresses of a shifting healthcare system (Mullahy, 1995). Despite sharing the common goal of the patient's well-being, physicians and case managers can easily become adversaries when distrust surrounding the case manager's intentions is raised. Comments such as "Case managers are the police who work with the insurance payers to deny care" misguide physicians into perceiving case managers as a threat to their medical judgment and their income. As a result of the changing working relationship between case managers and physicians (and others such as nurses, social workers, utilization coordinators, and discharge planners), the transition to a full cooperative and collaborative relationship is at times awkward and frustrating. Being caught up in past traditional roles hinders the establishment of the collaborative alliance necessary to achieve success in the healthcare of the twenty-first century.
     
We must constantly remind ourselves that we are all here for the patient and must remain focused on that goal. Case managers need to be especially clear on this point—that their interest is in ensuring better quality of care and the best possible outcomes. The physicians (or social workers, utilization coordinators, discharge planners) must be reassured that the case managers are not there to control or dictate practice but are instead there to foster effective, quality communication between members of a multidisciplinary team.
     
Today's case managers face the challenge of dealing with a diverse customer population. The case manager must be capable of incorporating the communication techniques and skills reviewed in this chapter when communicating with the diversity of groups involved in patient care. For example, a group of growing prominence involved in patient care is the payer source or insurance company. The case manager must listen closely to what the payer is requesting and must clarify any vague communication at the outset. The case manager should not assume that the insurance claims department has all of the necessary knowledge with regard to a patient's discharge plan. The case manager, as educator and advocate, becomes vital to the success of the patient's outcome by sharing his or her medical knowledge of what the patient needs. Case managers must keep in mind that they are the problem solvers and cannot easily accept a simple "No" or "We don't do that." Case managers must be risk takers when communicating with the payer members of the team, or patients could suffer the consequences. The communication with external members of the multidisciplinary team (e.g., payer, community resources, family members) becomes just as important to the success of the patient's outcome as the communication with internal members.
     
Much of this chapter has been devoted to communication because it is perhaps the most vital skill that case managers must master. Although different communication styles exist (Box 1-3), case managers must use the assertive style in applying the case management process. However, psychological, physical, and structural barriers can cause turbulence in the information flow. Effective case managers will work fiercely to reduce these barriers. The more rapidly they receive and communicate information, the better the quality of the decisions they make will be (Case Manager's Tip 10).

Data Management
The use of data in case management continues to be of great importance. Case managers continually use data for decision-making purposes. They identify, collect, and analyze data when assessing their patients, implementing the required care and monitoring and evaluating the outcomes. This aspect of the case manager's role is important for information management, knowledge development, and enhancing the healthcare delivery system. Therefore case managers must possess appropriate skills in data management to succeed. They also must be able to use certain tools throughout their day for data collection and tracking. Examples of these tools are as follows:       Case managers must also understand the different methods of data collection and management (i.e., retrospective, prospective, and concurrent), their advantages and disadvantages, and when it is appropriate to use each of the methods. In addition, they must be knowledgeable in the types of measures used in data analysis, particularly those that are appropriate for use in case management evaluation, such as the following:       With today's reliance on automation in most data management systems and departments, case managers are expected to be able to access databases, run special reports, prepare graphic reports, conduct statistical analyses, and export or download data. Case managers with these skills are the most desirable and successful. When writing reports, they must be able to summarize the important findings, indicate the outliers and deviations from the norms or standards, and determine whether there is a need for more detailed or different types of data for better decision making or for more accurate interpretations and conclusions. Furthermore, case managers must be capable of writing concise, readable, and easily understood and interpreted reports.

Big Picture/Systems Thinking
Case management delivery models are grounded in systems theory. The delivery of patient care is dependent on the environment/context in which it is delivered and varies across time and space. For example, intensive care services are not provided in a clinic setting but rather in an acute care setting. Another example is using the emergency department for access to healthcare services at times of emergency and not as a primary care provision setting. Case managers must understand the differences in the types of services provided in the varied settings across the continuum. If they are not systems focused in their thinking and approach to care delivery and management, they will not be successful and effective.
     
Case managers are expected to interact with their system at three different levels: the individual, the organization, and the environment at large. They manage the care of the individual patients in the context of the care setting or level of care the patient is at. They also coordinate, facilitate, and arrange for the services their patients may require postdischarge or at the next level of care. This requires case managers to interact with other organizations and community agencies or managed care organizations for authorization of services; thus they reach out to other organizations and the environment at large. Regardless of the setting they are in, case managers are expected to employ a systems thinking framework and approach to case management care delivery. This framework assures them success and desirable outcomes.
     
According to Ridge and Bland Jones (in Lancaster, 1999, p. 36), systems thinking is defined as a "powerful problem-solving language that guides the understanding of complex issues within organizations, based on the assumption that organizations are made up of parts with patterns of interaction, rather than discrete structures and components." The complexity of case management models in relation to the scope of services, interdisciplinary approach, and continuum of care focus demands a systems approach to care delivery because of its interdependence on the various disciplines involved in care processes. Case managers must be able to pay careful attention to the environment in which they work and to its related inputs, throughputs, and outputs and the degree to which they interact. The inputs, throughputs, and outputs make up the various functions of case management such as resource utilization, strategic plans, care management activities, roles and job descriptions, goals, objectives, performance, productivity, and outcomes.
     
Senge (1990) views organizations as systems in which staff members interact and function in interdependent teams to accomplish the goals of the organization. This is true for case management systems. Case managers must be able to work collaboratively in teams and to facilitate the achievement of the goals of cost-effectiveness and quality outcomes. Senge (1990) emphasizes systems thinking as the desired approach for achieving such results. He adds that systems thinking is a powerful problem-solving strategy. Case managers must learn how to incorporate this strategy in their daily activities because it focuses on the essential interrelationships of the case management model and helps case managers to see and appreciate the "big picture" and the interconnectedness of the different components of the system or organization. Systems thinking assists case managers in the following ways:       Emotional Intelligence*
During the past decade, emotional intelligence has surfaced as a necessary skill for effective industry leaders. It has become even more important for those in healthcare; especially for case managers. Emotional intelligence is defined by Cooper and Sawaf (1996, p. XIII) as the "ability to sense, understand, and effectively apply the power and acumen of emotions as a source of human energy, information, connection, and influence." Goleman (1995), however, defined emotional intelligence as the ability to "motivate oneself and persist in the face of frustrations; to control impulse and delay gratification; to regulate one's mood and keep distress from swamping the ability to think; to empathize and hope." Both definitions emphasize the importance of self-awareness of emotions and the need to consider these emotions and feelings in the process of making decisions, instituting actions, or dealing with others.
     
Feelings and emotions, whether positive, negative, or neutral, serve as a source of vital information used in making decisions, initiating action, or communicating. They cause case managers to act in a certain way. They also influence how case managers may connect with themselves and others and establish relationships. How successful they can be in handling a particular situation or event depends on the following:

Emotions, if used and managed appropriately by case managers, act as a source of power, motivation, feedback, information, influence, innovation, creativity, success, and freedom. Based on the definitions presented, emotional intelligence enhances case managers' abilities with regard to the following:

Goleman (1995, 1998) identified five components of emotional intelligence: knowing one's emotions, managing emotions, motivating oneself, recognizing others' emotions, and handling relationships. The first three components are concerned with self management and regulation skills, whereas the remaining two are associated with building relationships, community, and social skills. These components are described as follows:
  1. Knowing one's emotions is the state of having a deep understanding of and insight into one's feelings, preferences, internal states, and drives and how they affect self, others, and job performance. Emotionally self-aware case managers are conscious of their capabilities and deficits and have better control over their actions, reactions, and interactions. Their decision-making ability is enhanced and they are more honest and sincere in their practice.
  2. Managing one's emotions is handling one's feelings, emotions, and internal states appropriately. It is the ability to control one's impulses, delay gratification, and regulate one's moods so that distress is prevented. Case managers who manage their emotions are able to withhold disruptive emotions, reactions, and decision making until relevant information is obtained. In addition, they are able to be flexible in handling change and to be responsible for personal performance. Case managers who manage their emotions are able to self-regulate. They are able to carry on effective internal conversations about feelings, emotions, and experiences so that they feel free of destructive emotions and thoughts and thus are able to channel emotions in useful ways for themselves, others, and the job.
  3. Motivating oneself is the act of taking the initiative for achieving goals and dreams. It is pursuing solutions to problems without waiting for others to take the lead or provide direction. Self-motivated case managers strive for excellence and align with the goals of the interdisciplinary team and/or the organization. They achieve beyond their own expectations and the expectations of others and what is expected for the job. They are passionate about and take pride in the job they are responsible for. Self-motivated case managers are able to "think outside the box" and to look for nontraditional solutions/approaches to solving problems and improving workflow. Self-motivation enhances their feeling of optimism even after a setback or failure to achieve, or after experiencing frustration.
  4. Recognizing others' emotions is the ability to recognize the feelings of others and to be more attuned to the subtle signals others send through their behaviors and interactions regarding their needs, wants, and desires. Case managers who have the ability to recognize others' emotions are more aware of others' needs and perspectives. They are able to express their interest in others' concerns and abilities and to work with them on meeting the interdisciplinary team goals. The ability to recognize and acknowledge others' emotions is known as empathy. It is essential for understanding and thoughtfully considering the feelings and emotions of others while making decisions or solving problems. Empathy enhances teamwork and unity and helps to bring members of the interdisciplinary healthcare team closer together. It also fosters loyalty to the team and the organization.
  5. Handling relationships is the ability to manage relationships and others' emotions effectively. Case managers who know how to handle relationships make those around them feel welcome, at ease, and an integral part of the team. They are effective on an interpersonal level and adept at inducing desirable responses in others. The ability to handle relationships well enhances group work and synergy and nurtures influential relationships. It helps to build social skills. This ability allows case managers to foster a sense of community. It is "friendliness with a purpose," moving people in the right direction. Case managers' effectiveness with regard to social skills depends on other components of emotional intelligence; that is, controlling and understanding their own feelings and emotions and empathizing with the feelings and emotions of others.
 The desired qualities of case managers are not limited to their technical, clinical, and interpersonal skills, abilities, knowledge, and expertise. These qualities are deemed most effective if they are coupled with the skill and ability to recognize, understand, manage, master, and appropriately respond to one's own emotions and feelings and those expressed by others, such as nurses, social workers, physicians, administrators, patients, and families (Case Manager's Tip 11). Case management responsibilities and services demand the presence of case managers who are astute and emotionally intelligent; otherwise these case managers would not be able to provide efficient, effective, safe, cost-effective, ethical, and quality care.

SUCCESSFUL LEADERS

Successful leaders possess quite an extensive list of skills. This is especially true of case managers as leaders. They must be able to incorporate all of the skills discussed previously into their day-to-day functions with the gracefulness of a gazelle.
     
As stated earlier, not everyone can be or aspires to be a case manager, even with proper education and development. Successful case managers are likely to demonstrate a special ability to operate in peer relationships, lead others in subordinate relationships, resolve interpersonal and decisional conflicts, communicate with the media, make complex interrelated decisions, allocate resources (including their own time), and innovate (Mintzberg, 1973). Successful case managers must be leaders, not managers. Leadership skills and abilities are more desired in case managers than management skills and abilities. Management has a more narrow focus: How can I accomplish certain things? Leadership, on the other hand, deals with the broader picture: What are the things that I need to accomplish? In the words of Peter Drucker and Warren Bennis, management is doing things right, whereas leadership is doing the right things. Management is efficiency in climbing the ladder of success; leadership determines whether the ladder is leaning against the right wall (Covey, 1989).
     
You can quickly see the important difference between the two if you envision a group of new graduate nurses cutting their way through a jungle. In the front will be the workers cutting through the undergrowth, cleaning it out. The potential managers will be behind them, sharpening their machetes, writing policy and procedure manuals, holding development programs, and setting up work schedules. The potential leader (case manager) is the one who climbs the tallest tree, surveys the entire situation, and yells, "Wrong jungle!" (Covey, 1989).
     
The metamorphosis taking place in almost every industry, including the healthcare industry, demands professional leadership first and management second. All that has been conveyed in this chapter clearly depicts the leadership qualities needed in today's healthcare environment. Although the title has generally become associated with management, leadership more fully and accurately defines the role of the case manager. Efficient management without effective leadership is "like straightening deck chairs on the Titanic" (Covey, 1989).
     
Effectiveness does not depend solely on how much effort we expend but whether the effort we expend is in the right place. It is irrelevant if a case manager spends days on a discharge plan, expending much energy, only to find out that as a result of poor leadership vision, the plan was not the right blueprint for the patient.
     
The pressure for change within our healthcare industry will most definitely intensify rather than diminish in the coming years. This pressure will require nurses to respond with new dynamic transformational leadership to cope with future changes. The transformational leader approaches leadership from an entirely different perspective or level of awareness. The transformational leader, as defined by Bass (1985), is one who does the following:       House (1971), who developed the path-goal theory in the 1970s, depicts the qualities of a transformational leader as someone who does the following: Although the research of both Bass and House dates back a number of years, perhaps these theorists were ahead of their time. The case manager of the twenty-first century characteristically has all of these qualities, and any organization interested in building a solid case management program should give consideration to them.

KEY POINTS
  1. Utilization of the nursing process—assessment, planning, implementation, coordination, and evaluation—is vital to a successful case manager.
  2. Assessment connects the physical and the psychosocial aspects of a patient's care.
  3. Planning determines the treatments and interventions necessary for meeting the needs of patients and families.
  4. Implementation/coordination builds on the plan and determines the goals of patient care, moving the plan to completion.
  5. Evaluation measures the patient's response to the case management plan.
  6. Leadership and communication skills such as facilitation, negotiation, utilization management, education, team building, and conflict resolution must be added to the case manager's repertoire and put to use daily.
  7. Teamwork is essential to the success of any patient plan. Learn who the members of the team are and develop effective relationships.
  8. Acquired skills are applicable to all forms of case management, including acute, subacute, home care, and insurance case management.
REFERENCES

Bass B: Leadership good, better, best, Organiz Dynam 13:26–40, 1985.

Bower XA: Case management by nurses, ed 2, St Louis, 1992, American Nurses Association.

Case Management Society of America: Standards of practice for case management, Little Rock, Ark, 2002, The Society.

Cooper R, Sawaf A: Executive EQ: emotional intelligence in lead- ership and organizations, New York, 1996, Berkley Publishing Group.

Covey S: The 7 habits of highly effective people, New York, 1989, Simon & Schuster.

Dash K, Vince-Whitman C, Zarle N, et al: Discharge planning for the elderly: a guide for nurses, New York, 1996, Springer.

Goleman D: Emotional intelligence: why it can matter more than IQ, New York, 1995, Bantam.

Goleman D: What makes a leader? Harvard Business Rev 76(12):93–102, 1998.

Haase J: The 10 elements of an effective team, Home Care 38:236, 1992.

House R: A path-goal theory of leadership effectiveness, Admin Q 16:321–338, 1971.

Kirsch J: The middle manager and the nursing organization, East Norwalk, Conn, 1988, Appleton & Lange.

Lancaster J, Lancaster M: Communicating to manage change. In Lancaster J: Nursing issues in leading and managing change, St Louis, 1999, Mosby.

Maslow AH: Motivation and personality, ed 2, New York, 1970, Harper & Row.

Mintzberg H: The nature of managerial work, New York, 1973, Harper & Row.

Mullahy CM: The case manager's handbook, Gaithersburg, 1995, Aspen.

O'Malley J: Dimensions of the nurse case manager role: case management (Part II), Gaithersburg, Md, 1988, Aspen.

Powell S, Ignatavicius D: CMSA core curriculum for case management, Philadelphia, 2001, Lippincott Williams & Wilkins.

Rawlins C: Harper Collins college outline: introduction to management, New York, 1992, American Book-Works.

Ridge R, Bland Jones C: Systems theory and analysis in health care and nursing. In Lancaster J: Nursing issues in leading and managing change, St Louis, 1999, Mosby.

Rorden JW, Taft E: Discharge planning guide for nurses, Philadelphia, 1990, WB Saunders.

Senge P: The fifth discipline: the art and practice of the learning organization, New York, 1990, Doubleday/Currency.

Umiker W: Negotiating skill for health care professionals, Health Care Superv 14(3):27–32, 1996.

Yura H, Walsh M: The nursing process, East Norwalk, Conn, 1983, Appleton-Century-Crofts.
Glossary          

Appendix A
Appendix B
Appendix C
Appendix D
Appendix E-1 Appendix E-2 Appendix E-3
Appendix F
Appendix G
Appendix H
Appendix I
Appendix J
Appendix K
Appendix L
Appendix M
Appendix N
Appendix O


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