Care Management and Coordination
Care management is the systematic identification, assessment, planning, facilitation, and evaluation of services for a person with complex needs. Know the core workflow: case finding (risk stratification, predictive modeling, referral triggers), comprehensive assessment (medical, functional, social, behavioral, caregiver), individualized care plan with measurable goals, care coordination and referral management, monitoring, and reassessment with transition planning. Distinguish the case manager (coordination and advocacy) from the care coordinator (logistics) and the social worker (psychosocial counseling and resource linkage); questions often test who owns which task.
Understand levels of intervention - case management intensity scales with acuity, from low-touch education to high-touch frequent contact. Know the difference between disease management (condition-specific, population-based) and complex care management (whole-person, high-cost, high-need).
Common traps: confusing advocacy (acting on behalf of the patient's expressed wishes) with paternalism (substituting the clinician's judgment); assuming the case manager can make clinical decisions (they coordinate, but prescribing and diagnosis remain with licensed providers); and forgetting that the patient's own goals drive the plan, not the clinician's targets. Another trap is conflating eligibility for a program with appropriateness.
Rule of thumb: If a question asks what the case manager should do first, the answer is almost always to assess or to clarify the patient's own priorities and consent - not to enroll, refer, or discharge.
Worked example: A 78-year-old with heart failure, diabetes, and two recent admissions is referred. Before arranging home health, the case manager completes a comprehensive assessment including caregiver capacity and health literacy, then builds a plan with the patient's stated goal (staying home). Referrals follow the assessment, not precede it.