Case Management Process
This domain tests the end-to-end case management process: how a case is identified, assessed, planned, coordinated, monitored, and closed, and how standards of practice shape each step. Expect sequencing questions, documentation issues, and role boundaries with the interdisciplinary team.
Core sequence
- Screening/case finding uses referral criteria, risk stratification, or predictive modeling to identify candidates. Screening is not assessment.
- Assessment gathers biopsychosocial, functional, financial, environmental, and patient-preference data; validated tools improve reliability.
- Care planning sets patient-centered, measurable goals, timeframes, roles, and contingency plans, negotiated with the patient, family, and team.
- Implementation/coordination links resources, advocates, and plans transitions.
- Monitoring/evaluation compares progress with goals and revises the plan when variance occurs.
- Closure requires met criteria, a self-management plan, a written summary, and patient agreement. The process is cyclic, not strictly linear.
Worked example
A 68-year-old with three CHF admissions in six months is flagged by risk screening. Assessment finds medication cost barriers, no scale, and no follow-up ride. The plan includes a pharmacy assistance referral, a telehealth scale, teach-back on daily weights, and a ride to a 7-day appointment. Monitoring uses weight logs and a 72-hour call. Closure follows 30 stable days and demonstrated self-management. Reasoning: every intervention maps to an assessed need, goals are measurable, and closure is not premature.
Traps
- Writing a plan before completing assessment.
- Treating screening as a full assessment.
- Acting as decision-maker rather than facilitating patient autonomy.
- Omitting variance documentation or closure criteria.
- Confusing case management with utilization review.