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

PURPOSE: 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. PRIMARY PRACTICE SETTINGS: 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. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: 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.

Improving Care Transitions to Drive Patient Outcomes: The Triple Aim Meets the Four Pillars.

PURPOSE: The purpose of this article is to examine how case managers can support positive outcomes during care transitions by focusing on the goals of the Triple Aim () and Coleman's Four Pillars (). Case managers can play a pivotal role to ensure high-quality transitions by assessing patients and identifying those who are at high risk; coordinating care and services among providers and settings; reconciling medications; and facilitating education of patients and their support systems to improve self-management. These activities are congruent with an underlying value of case management as defined by the Code of Professional Conduct for Case Managers: "improving client [i.e., patient] health, wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation" (). CASE MANAGEMENT PRIMARY PRACTICE SETTINGS: Case managers across health or human services must assess for, identify, and understand the vulnerability of patients during care transitions and must adopt best practices to support successful care transitions. This includes case managers in acute care, primary care, rehabilitation, home health, community-based, and other settings. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Two frameworks that support care transitions are the Triple Aim of improving the individual's experience of care, advancing the health of populations, and reducing the costs of care (), and Coleman's "Four Pillars" of care transition activities of medication management, patient-centered health records, follow-up visits with providers and specialists, and patient knowledge about red flags that indicate worsening conditions or drug reactions (). From a case management perspective, these approaches and their goals are interrelated. As an advocate for the individual and at the hub of the care team, the professional case manager engages in important activities such as facilitating communication across multiple providers and care settings, arranging "warm handoffs," undertaking medication reconciliation, and engaging in follow-up, particularly with high-risk patients. To support successful transitions of care, case managers must adopt best practices and advocate within their organizations for systematic approaches to care transitions to improve outcomes.