Last week, a manager of a case management department emailed me asking for tips to help her educate her team on case management care planning. She said that she was working with her staff on fine tuning how they develop goals to better document their outcomes. This is a common challenge many managers face when trying to help their staff document the work they do and prove the value that the individual case manager and the department bring to their organization.
In thinking about this and how to answer the request, I thought about the following key points:
- The process of case management provides an organized, structured approach for transitioning patients through the continuum of care toward the goal of self-sufficiency.
- In order to set goals that are patient specific, the patient needs to be actively involved in all phases of the process: assessment, planning, problem solving and finding resources.
- The patient is responsible for the outcome while the case manager is responsible for the process.
- The case management process attempts to influence change that enables the patient to achieve her goals.
Providing a specific answer to the inquiry is impossible because I don’t have the information needed, but in general case managers work with patients with a variety of issues and challenges. As each case is different, determining goals requires clinical expertise, an assessment of the patient’s current status, and learning what the patient’s goals are. The case manager is the one member of the health care team whose role is to advocate for the patient in order to ensure those goals are identified and kept in mind as the plan of care is developed.
If you are a workers’ compensation case manager helping an injured worker, the overall goal would be to return the injured worker to gainful employment. The process of how to return the patient to gainful employment is up to the case manager, the treatment team, the employer and the injured workers. The case manager brings all involved together to determine a plan of care and set long- and short-team goals with the vision of returning the injured worker to gainful employment. The case manager must be proactive in monitoring the plan of care to ensure it stays on track. If barriers occur, then they are identified early and addressed so that setbacks/exacerbations do not occur. The plan may have to be adjusted due to changes in the patient’s condition.
The same applies to patients with other catastrophic or chronic conditions. The key questions all involved must answer include, What are the patients goals? and What are the needs that must be addressed to reach those goals? Gaining answers to these questions will assist the case manager and the treatment team in developing a plan of care that meets the patient’s goals and addresses the issues that arise. Again, the case manager is at the center to advocate for the patient and assist him in understanding the plan of care so he can actively participate to achieve his goals and move toward wellness in spite of disease.
In general, goals should be:
- Based upon the assessment and the individual needs of the patient.
- Based upon a timeline.
- Reviewed and updated to ensure the patient is moving toward meeting the goal and, if not, a process to determine why.
- Restructured based on the patient’s progress or lack of progress.
I hope each case manger takes the process of goal setting seriously and works collaboratively with the team to come up with goals that shows the value case managers bring to the file. The goals you set provide the answer to the question, Why is a case manager involved in this case? If you cannot answer this question through the goals you set, than you probably don’t need to be involved.
The goals you set today become the outcomes that validate the need for case management interventions. As professionals, case managers need to be able to demonstrate their value and goal setting is key to the process.
I invite you to share resources that you have used to educate yourself or your staff on the care planning process and goal setting. How have you taken the theory and applied it to a real life situation? Email me at and I will compile and share with readers in next week's Case In Point Weekly.
Have a great week!