The advent of the Patient Protection and Affordable Care Act of 2010 (PPACA), Value-based Purchasing (VBP), the Institute for Healthcare Improvement's (IHI's) Triple Aim, and the National Strategy for Quality Improvement in Health Care has pressured health care stakeholders to focus on quality, safety, and cost of services and resources more than ever before. These priorities may sound simple and similar in focus. The reality, however, is that they are complex and require the collaboration of stakeholders from across the health care continuum, care settings, providers, payers, employers, and, most importantly, consumers. There is no better time than now to focus on advocacy as an essential strategy, embedded in case management programs. Such strategic attention to advocacy enhances the capabilities of health care delivery systems and assists in meeting the challenges of the Triple Aim and the priorities of the National Quality Strategy while meeting the expectations of the PPACA and VBP programs. There is no doubt that advocacy in case management contributes to improving the client experience of care including quality and satisfaction, improving the health of populations, and reducing the per capita cost of health care (IHI, 2016).
The IHI explains that the Triple Aim presents a framework for health care organizations to use in optimizing the performance of their care delivery systems. However, the IHI claims that currently no one care setting demonstrates accountability for all aspects of the Triple Aim (IHI, 2016). Therefore, breaking down traditional barriers and pursuing collaboration across care settings and providers are important to achieve the goals of better care experience, better population health, and lower cost. Case management is poised to play an important role in moving health care systems toward addressing the challenges of the Triple Aim. Advocacy is integral to the case management approach and known to improve the client's experience of care and ensure better service quality and safety as the client transitions across the complex continuum of care and diverse providers. Case managers today through their involvement in care coordination, transitions of care, interdisciplinary collaboration, and provision of timely access to care for clients and their support systems are found to be advocating for these clients every step of the way and beyond any one particular care setting or provider. Despite the importance of such role, case management experts and leaders are yet to focus on understanding the meaning of advocacy for the case manager and its value in care delivery and the improvement of the client's experience of care.
This two-part article provides those directly or indirectly involved in case management practice with a primer on advocacy. It also is a call to action for you as both case managers and leaders, urging you to pause and evaluate the state of advocacy in your programs and perhaps conduct a gap analysis by comparing your current advocacy practices with the knowledge and tactics provided in this article. Part I explores the ethical theories and principles of advocacy, the perception of case management-related professional organizations of advocacy, and types of advocacy. Part II presents a client advocacy model for case managers to apply in their practice, describes the role of advocacy in client engagement, identifies important strategies for the enhancement of client advocacy, and explains the set of essential competencies for case managers for the effective execution of their advocacy role. Finally, this two-part article urges you to develop strategic goals on advocacy for your case management programs and use the knowledge provided herein for that purpose, especially in designing case managers' advocacy-related competencies; articulating specific advocacy actions for each of the phases of the case management process; and identifying advocacy-based measures for use in the evaluation of the client experience of care and other quality and safety program goals.
The author published a version of this article initially in 2005 (Tahan, 2005). More than a decade later, although advocacy has taken a center-stage position in our case management practices, as evident in the codes of ethics and professional conduct for case managers, standards of case management practice, and client/support system-centered care, not much has been published about advocacy and innovations in its integration in the roles of case managers. An exception is the concise mention of advocacy in case management-related codes of ethics and standards of practice. This two-part article attempts to fill this continued gap in the case management advocacy literature.
Advocacy: A Must Focus for Case Management
The concept of advocacy is not new to health care service delivery and practices. It is an important and powerful aspect of case management. It also is specifically embedded in the role case managers play in the provision of care to clients and their support systems. It is inherent in every activity they perform, from diagnosis of clients' problems to recovery or death, that is, across the continuum of care, while providing health and human services, and during every encounter with a client. Advocacy is at the heart of the case manager's role and the relationship with the client and client's support system. It is a moral and ethical obligation that can be evident in the decisions and actions of case managers when managing, coordinating, and facilitating health care delivery; deciding on the appropriate use of resources; and enhancing quality and safety outcomes for their clients/support systems. Moreover, advocacy is an essential element of interdisciplinary collaboration, communication, and cooperation for the purpose of meeting and respecting clients' needs, desires, interests, and preferences.
Case managers are constantly challenged to maintain a delicate balance while managing health care activities and resources and facilitating a client's informed decision making. On the one hand, they must identify, assess, and meet the needs and wishes of the clients (i.e., patients and their families and caregivers). On the other hand, they must acknowledge the interests of the provider (e.g., physician, hospital), the employer, and the payer (e.g., insurance company or third-party payer). The key strategy to maintaining the balance is advocacy—a fundamental and vital role for all case managers regardless of practice or care setting and professional background.
Case managers in any practice setting are ideally suited to advocate for clients while dealing with the realities of the cost-conscious, managed care environment (Hellwig, Yam, & DiGiulio, 2003), which tends to focus on “financial bottom line” decision making. Although multiple factors influence the need for advocacy, it is generally true that someone in the health care environment must assume the role of client advocate, particularly for the client whose self-advocacy capability is impaired. Case managers are, without any doubt, in the ideal position to assume this role because of their ability to determine the appropriate amount, type, quality, option, and timing of advocacy required by different clients.
Advocacy provides a powerful context for the many tasks, roles, functions, and responsibilities of case managers. They can achieve this by continually raising the questions: What are the client's care goals, wishes, and preferences? What is in the best interest of the client and client's support system? And is the client/support system capable of self-advocacy? Case managers may use advocacy as a way of showing their clients that they are on their side and they are their top priority. They are able to “work the health care system” both within and outside the care setting (e.g., hospital) walls, and across the continuum of care and various involved providers, to ensure that the clients' needs and care goals are met, resulting in optimal care experience for all. The need for case managers to act in such role is even more pronounced because of the current climate of health care delivery that relies on case management as a desired strategy for ensuring the delivery of cost-conscious, efficient, quality, ethical, safe, legal, and culturally relevant health care services. This two-part article summarizes some of the essential descriptions of advocacy noted in select case management-related literature in Part I, discusses a model and several practical strategies case managers may use to execute their role as client advocates, and shares an effective approach to advocacy: “maintaining a delicate balance” in Part II.
Describing Advocacy and Its Purpose
The term “advocacy,” as it appears in the literature, is described as the “essence” of the client–case manager relationship. Advocacy is predominantly client-focused rather than provider-driven; in fact, it is provider (i.e., case manager)-facilitated. Advocacy simply means actively supporting a cause and trying to get others to support it as well. It also is speaking up, effecting change, drawing attention to an important issue or interest, or directing those who are to make certain decisions toward an appropriate and necessary action.
Generally, advocacy aims to promote or reinforce a change in one's life or environment, in program or service, and in policy or legislation. In health care delivery, these activities focus on health conditions, health care resources, quality of life, and the needs of clients/patients and the public. Advocacy has been defined in several different ways. However, there is no single right definition or approach to advocacy. This article respects and affirms the rich diversity of advocacy experiences and perspectives case managers possess that tend to rely on the context of their work environment, the client populations they serve, and the goals and objectives of the case management programs they belong to.
Advocacy has been discussed and defined in great detail in the public and social policy literature. However, in case management, it has not been reviewed or described as comprehensively even today despite its importance. The limited, but varied, definitions of advocacy communicated in the case management literature share certain core characteristics. Advocacy is noted to be similar to friendship in that it is best when based on open communication, transparency, connection, honesty, respect, truthfulness, and trust; similar to counseling because it is most effective when applying listening, attending, supporting, empowering, engaging, and responding skills; and similar to teaching when it involves patience, guidance, and sharing of information by a more knowledgeable individual.
Advocacy entails the pursuit of influencing outcomes—including public policy and resource allocation decisions within political, economic, and social systems and institutions—that directly affect people's lives. It consists of a set of organized efforts and actions that effect change in a decision maker's perception and understanding of a problem, issue, or reality with the purpose of bringing clear improvements in one's life. In case management, advocacy is a professional and proactive case manager's activity or intervention that requires advanced knowledge, competence, and skills and focuses on achieving what is in the best interest of the client/support system while maintaining the client's autonomy and self-determination. Case managers engage in advocacy activities at every step of the case management process while:
- Assessing clients' needs and those of their support systems.
- Planning, facilitating, coordinating, managing, and integrating required health care services and support resources.
- Monitoring and evaluating the delivery of services and clients' responses.
- Transitioning the clients from one level of care/setting or provider to another.
- Educating clients about and engaging them in their treatment plans, tests, and procedure, health care regimens, building self-care and self-management skills, and understanding how to navigate the complex health care system.
- Monitoring and addressing patient care delays whether related to tests and procedures or responding to their results in an effort to progress care.
- Communicating with payers (e.g., insurance companies such as managed care organizations) regarding the clients' conditions and treatment and transitional plans.
- Obtaining authorizations for treatments and services necessary for providing care to clients.
- Facilitating shared and informed decision making concerning care options.
- Being transparent with the client and support system regarding care progression, quality and safety concerns, and cost of services.
Contexts and Underpinnings of Advocacy
It is no surprise that the few definitions of advocacy in case management practice available in the literature focus on an ethical and legal foundation for such practice (see Table 1). For example, Hawkins, Veeder, and Pearce (1998) describe advocacy as a process that aims to promote client empowerment, independence, and autonomy. According to them, case managers as advocates have an obligation to create an environment that allows the client and/or client's support system to act in their own best interest, and if they were unable, the case manager will then take on their cause, act on their behalf, defend the cause, and support the client and support system in meeting their health care goals. Examples of this type of case manager advocacy include activities such as fostering clients' independence; educating clients about their rights, health care services, resources, and benefits; facilitating appropriate and informed decision making; considerations for clients' cultural values, factors, and interests while delivering care; and identifying clients in need for advocacy to act on their behalf.
Raiff and Shore (1993) focus on service provision in their description of advocacy; that is, being fair and just in the distribution of services and resources. They define advocacy as a process designed to address deficiencies that clients encounter when choosing, accessing, or using service providers. In this situation, case managers assist their clients in gaining access to all of the benefits they are entitled for, thereby securing or enhancing a needed service, resource, or entitlement. Examples of this type of advocacy include activities case managers may engage in to first “make existing services available to clients; [second], to make existing services meet client's needs; and [third], to develop services to address unmet client needs” (Raiff & Shore, 1993, p. 55).
Pinch (1996, in Flarey, Smith, & Blancett, 1996), however, focuses on bridging the ethical and legal dimensions in the process of advocacy and the practice of case management. She states that client advocacy has two facets. The first entails the provision of information by the case manager so that the client can make informed decisions about treatment options, whereas the second is supporting the decisions the client makes. According to Pinch, case managers as advocates ensure that the clients possess the appropriate and relevant information regarding their health condition, plan of care, and treatment options before self-determination can occur. From the legal perspective, she asserts that the case manager must provide the clients with the particular level of information necessary for the process of making informed decisions. Ethically, however, she states that case managers are obligated by the “code of professional conduct” to take on the additional responsibility of supporting the clients in the informed decision-making process regardless of whether their decisions were desirable. Ultimately, the case managers have a moral obligation to be nonjudgmental. They also have a moral commitment to enhance clients' autonomy and to ensure that the clients receive and understand essential and relevant information and that their rights are protected.
Hellwig et al. (2003) agree with Pinch's perspective of advocacy as a legal and ethical process. They describe advocacy as a philosophical foundation for ethical and legal case management practice, a moral commitment to enhancing client's autonomy, and a process for protecting the most fundamental human right: freedom of self-determination. According to Hellwig et al. (2003), case management activities reflective of advocacy may include “helping the patient to obtain needed healthcare services, assuring quality of care, defending the patient's rights, and serving as a liaison between the patient and the healthcare system” (p. 54).
Daniels (2009),Treiger and Fink-Samnick (2016), and Cesta and Tahan (2016) describe a more contemporary perspective on advocacy—one that is not only grounded in the principles of ethical practice but also influenced by current sociopolitical issues such as the PPACA and VBP programs. Daniels (2009) describes advocacy for the hospital-based case manager as actions that adhere to the ethical and professional code of conduct and the standards of case management practice. She also explains that for case managers to support the best interest of their clients, they must be proactive advocates and the “voice of the client” in care management decisions. Daniels (2009) continues to indicate that “every interaction must be approached from the perspective of the patient's [(i.e., client's)] clinical and financial best interests, and every case manager work activity must, at its heart, support the case manager's advocacy role” (p. 49). Ultimately, Daniels (2009) recommends that case management practice must move away from task orientation to client-centeredness, which can be achieved by building a client–case manager relationship that shifts the interactions from routine questioning to intimate exploration of care options and client empowerment. In this regard, Daniels (2009) emphasizes that case managers must view client advocacy as an unwritten contract between the case manager and the client.
Treiger and Fink-Samnick (2016), similar to Daniels (2009), explain advocacy from an ethical perspective as a moral and professional obligation. They also describe it as an essential case manager's competency and a powerful context for case managers when executing their roles, responsibilities, and functions that include the building of a respectful and empowering client–case manager relationship. One of the most valuable contributions of Treiger and Fink-Samnick (2016) to the knowledge and practice of case management advocacy is their framing of it as a necessary competency every case manager and leader must develop, demonstrate, and advance on an ongoing basis. They stress the need for such competency as an obligation rather than luxury; that is, an integral component of every case manager's role and case management program (Treiger and Fink-Samnick, 2016).
Cesta and Tahan (2016) bring another dimension to advocacy, one that is of great importance to clients and their support systems as well as other stakeholders involved in care: quality and safety. They highlight the ethical aspects of advocacy similar to those described by Hawkins et al. (1998),Hellwig et al. (2003), and Pinch (1996). However, they go further and describe advocacy as essential to shared decision making, respecting the client's right to choice, protecting the client's health and safety, and ensuring the delivery of quality and safe care (Cesta and Tahan, 2016). This perspective on advocacy enhances the client's experience of care, which is integral to VBP programs, the IHI's Triple Aim, and the National Quality Strategy. It also modernizes our view of advocacy as an important strategy to respond to the demands of today's health care environment that places the client and community at the center of care delivery.
Four Primary Perspectives on Advocacy
It is sometimes unclear how much, how often, and to what degree case managers must be involved in clients' advocacy. A rule of thumb case managers may apply is first “allow clients to advocate for themselves to the extent they can.” Case managers' approach to advocacy is dependent on their perspective or framework (see Table 2). It also is affected by other factors such as the client–case manager's relationship; the context of practice; the case manager's skills, knowledge, and competencies; the client's level of functioning, cognition, alertness, interests, and willingness; and the situation at hand.
Hellwig et al. (2003) applied two perspectives when they explained the many definitions of advocacy available in the literature: traditional paternalistic and contemporary empowering. The traditional paternalistic perspective assumes that the client is powerless, passive, and lacks sufficient knowledge. In contrast, it describes the case managers as the “boss” and to have far wider knowledge about the health care system and more power based on their professional connections than their clients. Because of this, the clients may not always be able, or perhaps willing, to determine what is in their own best interest. The clients may not want the information, or they may not be able to understand it, and therefore case managers must be directive and act on their behalf; that is, be the client's voice and decision maker.
The contemporary empowering view, however, assumes that knowledge is power and that it is the absolute necessary commodity case managers may use to enable clients to make informed decisions, be their own voice, and be empowered participants in their care. According to this perspective, case managers assume that their clients are active participants in their care and in making its related and necessary decisions, have choices, and voice their opinions regarding their treatment options, interests, and plans of care. Case managers also maintain that the clients are the key architects of their own life, lifestyle behavior choices, and health care services in the form of the care options they choose and that no one knows what is best for the client other than the client himself/herself. Regardless, however, both perspectives stress the importance of the case manager's role as a client educator, counselor, and supporter.
Taylor (2005, in Cohen & Cesta, 2005) agrees with the two perspectives described by Hellwig et al. (2003); however, she adds a third that seems more practical and realistic. It is the perspective of shared responsibility; that is, advocacy driven by shared decision making between the case manager and the client. This view is based on a moral commitment to the client's autonomy and self-determination. It primarily respects the roles played by both the case manager and the client and their contributions to informed decision making that is usually a by-product of shared knowledge, discussions, and opinions. What is of great importance in this perspective is that the client/support system make decisions that are based on what is right for them and consistent with their values, beliefs, culture, moral identity, and level of comfort.
The shared responsibility perspective describes objectivity as being relative. It rejects the approach of noninterference by the case manager as well as the absolute passive and powerless state of the client. Rather, it emphasizes the nature of intersubjectivity of decision making resulting from the role of the case manager as a client educator, counselor, and supporter. This intersubjectivity occurs as the case manager and the client develop own meanings and perceptions of things while addressing the situations at hand requiring acts of advocacy. Case managers interject their own professional opinions as they assist, educate, counsel, and support their clients. Such interjections are based on the case managers' knowledge and previous experiences, as well as their obligations to ensure their clients make informed decisions. Similarly, and at the same time, the clients contribute their own opinions and share their knowledge of their care; such sharing is influenced by their previous experiences as well. As a result, advocacy decisions are made jointly on the basis of the exchange of knowledge and the collective agreements reached by both the case manager and the client. What is important about the shared responsibility and decision-making perspective is that it communicates to the clients they have different options and they can choose what makes most sense to them. It also denotes to them that the decision is theirs to make. The case manager is their supporter, educator, facilitator, resource person, and counselor during the process and available to assist them in arriving at a decision.
Another perspective on advocacy that has recently been gaining increasing interest is the engaging approach. This takes the empowering and shared responsibility perspectives one step further where the case manager partners with the client/support system and acts in an intentional manner to enhance the client's ability to adhere to care expectations, acquire self-management capabilities, actively adopt healthy lifestyle behaviors, and demonstrate mastery in the management of own health needs. This perspective is grounded in the client activation and engagement theories, which are borrowed from the counseling field, and is thought to contribute to improvement in individual and population health (one of the IHI's Triple Aims and National Quality Strategy goals), one client at a time. The engaging perspective is contemporary; it uses client activation to determine readiness for change and willingness to participate in self-care and self-management activities. Case managers in this approach are the catalysts for change. They place what is in the best interest of the clients at the center of the case management role and empower their clients to assume the driver seat; that is, determine care goals, where to start the change process, and when, how, and at what pace.
The engaging perspective respects the client's autonomy, right to self-determination, and choice. It expects the case manager to refrain from judgment or acting in a critical manner toward the client/support system. Through counseling-like interactions, case managers assist their clients/support systems to verbalize their fears and misconceptions and tackle the barriers standing in the way of change. This is advocacy at its best where case managers:
- Identify what is in the best interest of their clients;
- Support their clients in their journey of discovery of their strengths and identification of their fears, no matter where they are regarding their health and lifestyle;
- Establish through shared decision making a plan of care that is client-centric and consists of interventions that are reflective of the client's readiness for change and is based on the activation level; and
- Facilitate a supportive and transparent care environment where the client's experience of care (i.e., quality, safety, affordability, access, and perception) is a top priority.
Given these four perspectives on advocacy, case managers must rely on the shared responsibility, contemporary empowering, or engaging approaches. They also must avoid the paternalistic approach to advocacy because it neglects the client's autonomy or right to self-determination or, in the least, places it at risk. However, case managers may use the paternalistic approach in unique situations when clients are unable to advocate for themselves or when the clients resist the case managers' attempts to encourage the clients to make their own decisions, express their interests, communicate their choices, or gain knowledge about their rights and health care services and benefits. To establish a consistent approach to advocacy, one may say it is best to use the engaging perspective because it considers both empowerment and shared responsibility as integral components without which engagement may not occur.
Experts may classify the acts of advocacy in case management practice into four classes (see Figure 1) depending on their scope, extent of reach, complexity, and degree of impact on the client, health care system, population, and care outcomes. Case managers demonstrate advocacy behaviors to assist an individual client, a whole population of clients in a specific community, or the public at large. Case managers also execute these behaviors with the primary purpose of influencing the health of both the individual client and the public in a specific locale or at a national or international level.
Classifying acts of advocacy into groups based on similarities in scope, reach, complexity, and impact allows case managers to understand these acts and better determine which ones are most appropriate to address a specific situation. For example, advocating for the implementation of a program for calling clients after an episode of care or health encounter may not necessarily affect the health condition of a particular client unless if the use of the program allows for modifications to meet the specific needs of the individual client. Therefore, understanding the levels of advocacy and gaining clarity on the aim of an advocacy action and the depth and breadth of its reach in advance of execution are essential for the case manager's success. Case managers may apply four determining factors or criteria in their approach to classify advocacy:
- Reach: This criterion pertains to who the advocacy act affects: is it an individual client, a population of specific illness or in a particular locale, or a system at large (e.g., health care delivery system in the United States), which means the act affects virtually every person at a country level. An example of reach is a advocating for a change in a health care law resulting in all individuals in the country experiencing the result of the change (system level). Another example is advocating for the significant other of a client hospitalized and in critical condition to stay with the client overnight at the hospital (individual level).
- Scope: This criterion addresses the depth and breadth of the advocacy act; is it internal to an organization and affects the clients served by this organization or external and affects the population at large. For example, advocating for extending clinic hours into the evening allows more clients to access primary care services (organization and internal level). Another example is advocating for an outreach and health screening program that may affect the population in the service area (community level).
- Complexity: This criterion reflects the degree of sophistication or difficulty in executing the advocacy act: is it simple and pertains to an individual client and/or a small group of clients within an organization, or complex and affects the whole population served by the health care industry. This criterion also describes the type and amount of resources (i.e., time, people, money, and equipment/technology) needed to implement the advocacy act. For example, advocating for remote monitoring and digital technology to enhance client engagement may assist an individual client or a client population (may extend up to community level). Another example is advocating for the use of navigators to assist clients in way finding around a care setting (e.g., hospital; individual client up to organization level).
- Impact: This criterion reflects the level of the contribution of the advocacy act and the extent of the outcomes it may potentially achieve: is it at the micro or macro level. An example is advocating for having specialty radiology diagnostic tests (e.g., magnetic resonance imaging) during extended weekend hours (individual up to organization level). Another example is advocating for a change in a state or federal health insurance law (community level if state and global level if federal).
On the basis of the aforementioned criteria, there are four types of advocacy: client, organization, community, and global. These are also depicted in Figure 1 taking into account how each of these types of advocacy reflects the four criteria. Client advocacy and organizational advocacy are considered more of internal and micro level, whereas community advocacy and global advocacy are more of external and macro level. Table 3 shares illustrative examples on each of the types.
Client advocacy, also known as individual advocacy, occurs at the level of a single client. Client advocacy behaviors are considered simple in scope and micro in nature because they impact one person at a time. They are often embedded in everyday case management practice, integral to the client–case manager relationship, and vary on the basis of the needs and interests of the individual client. In addition, they occur as the case manager assesses the needs of the client and implements the plan of care. Moreover, traditionally. they have been confined to the boundaries of an episode of illness/care. Today, however, these advocacy behaviors extend beyond an episode of care or care setting to supporting a client across the life span, especially when the client suffers from a chronic illness.
Organizational advocacy, also known as service advocacy, occurs at the level of a health care organization (e.g., hospital) or a program (e.g., diabetes center and chest pain center) within the organization. It involves actions that improve the efficacy and efficiency of services and systems of care delivery. Organizational advocacy is of moderate complexity compared with individual advocacy. Although it is implemented in response to recognized deficiencies in a program or organization, it is deemed proactive in nature because it improves or expands the care to be provided to a specific client population at a future time.
Community advocacy, also known as population advocacy, occurs at the level of the community at large served by an individual health care organization. It is of moderate to high complexity and of moderate system reach. It also involves proactive actions that improve the health of the community such as developing new services needed by the clients that otherwise would have remained nonexistent. Community advocacy actions tend to be macro in scope and more challenging to implement. They are costly and must comply with the health care laws and regulations of the specific state or county.
Global advocacy, also known as state or national advocacy, occurs at the broader scope that influences the health of the public at large. It is of high complexity and involves both proactive (e.g., lobbying for proclient regulations) and reactive (e.g., legislative class action appeals) actions that improve the health of the public regardless of geographical boundaries. Similar to community advocacy, global advocacy is macro in scope and impacts the conditions of systems of large scales. It is primarily political in nature and focuses on effecting change in health care policy, laws, and regulations.
Regardless of the advocacy type, case managers as advocates are able to impact the health conditions of clients at various levels. For example, working with an individual client suffering from uncontrolled diabetes and internally within an organization or care setting, the case manager is able to improve this client's health condition. Through an engaging approach to lifestyle behavior change and respect of this client's right to choice and self-determination, the case manager is able to achieve desired outcomes (i.e., better health, reduction of avoidable or unnecessary access to emergency services, and therefore reduction in cost). When this case manager continues to care and advocate for clients with similar conditions and applying same tactics, this case manager is able to move from advocating at the individual and micro level to contributing to the health of a client population (i.e., clients with diabetes) and therefore engaging in advocacy at the community, system, and external levels.
This example demonstrates that the various types of advocacy are interrelated and do exist on a continuum that reflects the degree of reach and impact. The wider the reach and the greater the impact are, the more complex the advocacy act is and the larger its contribution to realizing the Triple Aim and the priorities of the National Quality Strategy is. Case managers must understand that their involvement in day-to-day case management advocacy and at the individual client level allows them to effect change at the population and system levels as well; they are able to contribute to such broader benefit through their caring for one individual client at a time. On the contrary, case managers involved in social justice, public policy, and lobbying activities for a specific cause are able to contribute to change at the system level and external to (or beyond) the organization where they are employed and their practice setting. Ultimately, all types of advocacy activities are necessary for successful health system improvement and meeting the IHI's Triple Aim.
Ethical Foundation of Advocacy
The case management practice of advocacy is rooted in ethical theories and principles similar to advocacy in nursing, social work, medicine, and other health disciplines. It is a complex concept and requires case managers to be knowledgeable in ethical principles to be effective client advocates and demonstrate objectivity while truly advocating for their clients/support systems. Case managers may be ineffective advocates when they lack skills in demonstrating respect for clients' right to self-determination, for example. Practicing advocacy with a solid ethical base assists case managers to minimize or completely prevent ethical dilemmas, especially those that may arise between themselves and their clients or between the clients and other providers or the health care system. The ethical foundation of the practice of advocacy also enhances the case managers' adherence to the code of professional conduct of their professional discipline (e.g., nursing, social work) and that of case management. General ethical principles, such as autonomy, beneficence, nonmaleficence, fidelity, justice, and veracity, provide case managers with a solid foundation for effective client advocacy.
Case managers stand alongside their clients/support systems throughout an episode of care and/or beyond. Such position is best exemplified in the professional client–case manager relationship. What is fundamental to this relationship, which contextualizes the case manager as the client advocate, is the case manager's ability to act with objectivity and freedom from any external or adverse pressures and interests. Whenever case managers resign to these conflicting demands and neglect the obligation of objectivity, they essentially destroy or weaken their professional standing, independence, and fiduciary relationship with their clients and clients' support systems. Comparatively speaking, when case managers demonstrate an objective attitude and comfortable command of the general ethical principles, they become effective in bringing about beneficial outcomes for their clients/support systems, advancing the clients' well-being, and protecting their autonomy and rights to informed choice and self-determination. Case managers also ensure that all clients have equal access to health care services, at the time they need them. Here, there is an implicit requirement for case managers to engage in advocacy, as it is necessary to promote the well-being of clients and do what is in their best interest. This means that case managers as client advocates must always execute their actions while carefully considering the ethical underpinnings of client advocacy and professional practice.
Case managers are responsive to the changing needs of their clients/support systems, dynamics of health care delivery, and demands of the complex processes of interprofessional care provision. Often they are found to resolve conflicts, prevent delays in care, negotiate the availability of community-based support services, or manage ethical dilemmas such as end-of-life care concerns. Applying ethical principles and standards to these situations allows case managers to remain focused on the clients' care goals, achieve positive health care outcomes that maximize clients' quality of life, ensure safety, and respect clients' autonomy, wishes, and interests. The question then is “how do case managers determine what ethical principles apply to their practice of advocacy?” Treiger and Fink-Samnick (2016) note that a “range of case management standards now exists across professional associations and credentialing bodies” (p. 171), which offer guidance in answering this question. In fact, these highlight advocacy as an essential ethical principle case managers are ought to adhere to while caring for their clients and support systems and when working toward achieving desirable outcomes for their clients/support systems.
Case managers are bound by professional codes of ethics and standards that guide their practice (see Table 4). The Commission for Case Manager Certification (CCMC) describes in its Code of Professional Conduct that applies to board-certified case managers from diverse professional backgrounds a number of ethical principles that are important for advocacy. These include placing the public interest above that of the case manager, respecting the rights and inherent dignity of clients, maintaining objectivity in the relationships with clients, and acting with integrity and commitment to quality outcomes for clients, appropriate use of resources, and the empowerment of clients in a manner that is supportive and objective. In addition, the CCMC explains that case management practice is guided by the ethical principles of autonomy, beneficence, nonmaleficence, justice, and fidelity. It also describes advocacy as a means for improving client health, wellness, and autonomy through advocacy, communication, education, identification of service resources, and service facilitation (CCMC, 2015).
The Case Management Society of America (CMSA) expects case managers to advocate for their clients at the service delivery, benefits administration, and policy-making levels (CMSA, 2010). The CMSA emphasizes in its standards the obligation of promoting advocacy at both the individual and community or system levels. At the individual level, case managers promote clients' self-determination, informed and shared decision making, and autonomy; recognize and respect clients' needs, care goals, and strengths; facilitate access to necessary services; eliminate disparities; and empower the clients to engage in self-advocacy. On the community or national level, the CMSA encourages case managers to expand the availability of health care services to clients and engage in public policy (CMSA, 2010).
The American Case Management Association (ACMA) focuses on case management mainly in the hospital-based setting; therefore, its standards of case management advocacy address expectations from health care professionals involved in case management delivery systems including transitions of care. The ACMA describes advocacy as supporting or recommending the access to and creation of new services on behalf of clients/support systems with the ultimate goal of protecting clients' health, safety, and rights. Examples of case managers' role in advocacy according to the ACMA may include identifying the clients' legal decision maker, promoting clients' self-determination, respect for clients' choices and informed decisions, provision of culturally competent care, addressing suspected neglect and abuse of clients, facilitating full access to services and insurance benefits, and managing ethical dilemmas or conflicts (ACMA, 2013). On the basis of these examples, the ACMA seems to focus primarily on client (individual)-level advocacy.
The National Association of Social Workers (NASW) is another professional organization that defines ethical standards for case management, however, only for the social work case manager. It expects the social work case manager to advocate for the rights, decisions, strengths, and needs of clients and to promote clients' access to resources, community supports, and services (NASW, 2013). The NASW describes the advocacy role of the social work case manager at both the individual and community or national levels. At the individual level, the case manager demonstrates advocacy by ensuring that health care organizations and service delivery systems involve clients/support systems in decision making, enhancing clients' access to services based on their needs, and preparing clients for transition to other providers or discontinuation of services and ensuring such transitions do not create sudden interruptions and are not perceived as surprises by clients and/or their support systems. At the community or national levels, case managers advocates by seeking clients' input on programs, addressing service gaps and barriers, educating the public regarding health care needs and resources, engaging in social and political actions, and designing policy that enhances the care of underserved populations (NASW, 2013).
The American Nurses Association (ANA) focuses in its code of ethics on the nursing profession, which also means that nurse case managers must adhere to the code in their practice. Concerning advocacy, the ANA indicates that nurses promote, advocate for, and protect the rights, health, and safety of the clients. It describes nurses, including nurse case managers, as having an obligation to protect clients from harm, safeguard the clients' rights of privacy and confidentiality, and act on questionable practice that places clients at risk for suboptimal care and harm (ANA, 2015). These activities support advocacy at the individual client level. The ANA also communicates in its code of ethics for nurses the need to articulate nursing values, maintain integrity of the profession, and integrate principles of social justice into nursing and health policy. This reflects advocacy at the national level. In this regard, the ANA addresses nursing's responsibility toward rectifying social injustices and health disparities and advocating for changes in health policies at a global level (ANA, 2015).
On the basis of the codes and standards of ethics case management-related professional organizations promulgate and the ultimate purpose(s) of advocacy they describe, experts can decipher that the ethical practice of case management advocacy consists of the following seven areas of focus:
- Protecting client's autonomy, right to choice, and self-determination;
- Keeping the client as the central focus (i.e., provision of client-centered and culturally competent care) and promoting what is in the client's best interest;
- Ensuring client's engagement in informed and shared decision making;
- Enhancing client's access to equitable, timely, and appropriate health care services and resources;
- Safeguarding client's right to privacy and confidentiality;
- Improving client's health outcomes, safety, and quality of life; and
- Engaging in social justice, and health and public policy change efforts.
These areas of focus promote advocacy at the client or individual level except for one, “engaging in social justice, and health and public policy change,” which mainly addresses advocacy at the community or global level. It is natural that most of the activities are at the individual level because the large majority of case managers execute their services in the context of “one client at a time.” Despite the focus being mainly at the client level, these activities contribute to improvement in performance at the system level as well because of the cumulative experience of populations of clients. To effectively implement these seven requirements, case managers must demonstrate adherence to 12 key ethical principles (see Table 5). These principles govern the practice of case management advocacy and reflect the way the codes and standards of ethics-related professional organizations have chosen to promote advocacy. Neglecting any of these principles in one's practice may compromise the expectations of the advocacy role and potentially risk achieving targeted outcomes for clients. These principles describe what to expect from case managers who claim to be engaged in client advocacy. Case managers may refer to them as behaviors demonstrative of advocacy and grounded in ethical theories. Although it is necessary for case managers to demonstrate all 12 principles in their practice, some are more evident in the clients' behaviors than in the case managers' because of their powerful impact on clients/support systems. The principles of objectivity, goal orientation, confidentiality, altruism, accountability, obligation, and full disclosure are prerequisite behaviors and their absence in the case manager's approach to care provision results in lack of advocacy, which ultimately impacts negatively on the clients and their support systems. On the contrary, when clients/support systems exhibit behaviors demonstrative of the principles of informed decision making, shared decision making, empowerment, engagement, and autonomy, they imply that case managers have adhered to advocacy ethical principles, succeeded in their client advocacy role, and therefore ethical practice.
As a result of the recent increasing interest in case management advocacy, few community-based organizations have been founded with the exclusive mission of client advocacy. One example is the Patient Advocate Foundation (PAF), which uses a case management team to support clients and providers of care by eliminating obstacles clients and/or clients' support systems (patients) may face when they need to access health care services. This advocacy act may entail the provision of free case management services to those who are facing financial or health care access issues as a result of a chronic, life-threatening, or debilitating disease. The PAF also aims to enhance the quality of the health care services, safeguard clients through effective mediation and ensuring the availability of services upon demand, support clients in maintaining employment despite their chronic illnesses, and preservation of clients' financial stability relative to their health conditions and diagnoses (PAF, 2016). Although these organizations do not define and communicate professional standards for the ethical practice of case managers, they advance case management advocacy and highlight it as an integral element of case management practice. It is important for case managers to be aware of these and other similar organizations so that they bring them to the attention of the clients who may benefit from what they have to offer, especially when these clients are in dire need for community support resources.
Advocacy: A Three-Pronged Role for the Case Manager
Although advocacy is an underlying theme in virtually all the interventions undertaken by case managers, one may examine advocacy as a sole role. In fact, one could argue that all aspects of the role of the case manager are subsidiary to that of the “advocate.” This role is complex, challenging, and requires patience, tenacity, skill, and persistence. Advocacy is most necessary in situations of conflict, disagreements, uncertainty, or vulnerability. For example, advocacy is needed when certain services required by a client are unavailable or are being denied by a third-party payer such as a managed care organization. In this case, advocacy emerges as a balancing act among three interconnected, yet often opposing, parties: the client (patient and family), the health care agency or other clinicians (providers of care), and the insurance company (payer). Case management advocacy is also necessary when clients are vulnerable and benefit from the support of case managers such as in the case of clients who are deemed either incompetent or unconscious and unable to advocate for themselves or voice their opinions.
Case managers are challenged to balance their relationships with the clients/support systems, health care agencies/providers, and insurers. They must balance this relationship while keeping the primary focus on the client. In fact, they advocate first for the client; this is their top priority. Next, they advocate for the agency where they are employed and their fellow providers; and, third, for the insurance company as warranted. With these intertwined responsibilities and the need to find satisfactory solutions to complex issues, case managers' attempts of advocacy are in the form of a continual balancing act. However, the priority is always clear: “The needs of the clients” or the “clients come first.”
For the Client and Client's Support System
Advocating for the client and client's support system (family and friends) is a top priority for case managers. It takes place all the time and in every situation or aspect of care provision. It is enacted on the basis of what is best for and needed by the client. Case managers tend to work the health care system both within and outside the agency that employs them to ensure clients' needs are met. Advocating for the client also is evident in the quality of care and the plan of care or type of treatments/services that are provided. Advocacy for the client includes facilitating timely access to services, recommending necessary tests and procedures, expediting care progression, enhancing the quality of care and client's well-being, preventing or managing delays in care provision, and ensuring safety especially during care transitions. In addition, case managers encourage and support their clients in making informed decisions about their care options. Once the needs of clients are determined, case managers then provide them with the necessary knowledge and resources so that they are better able to act as their own advocates. Thus, advocacy on behalf of the client results in empowerment and engagement and supports the client's right to autonomy and self-determination at all times.
For the Health Care Agency or Provider
Advocating for the health care agency (e.g., hospital, skilled nursing facility, care professionals) means working with the agency's administrators/executives and care providers including physicians, nurses, social workers, and others toward the delivery of appropriate, safe, efficient, and effective care and a timely client disposition to the next level of care. It entails preventing risk management issues and negotiating with the insurance company (payer) to authorize the plan of care and the utilization of necessary resources, thus ensuring reimbursement. The goal of advocacy on behalf of the provider, including the hospital, is to enhance reimbursement and meet the agency's goals and targets while ensuring that clients receive safe, quality resources and services that are free of any risk for malpractice litigation.
For the Insurance Company or Payer
Advocating for the payer may be the least common and palatable form of advocacy for a case manager who is practicing in a provider setting. It typically puts the case manager in the “messenger” role, communicating the insurer's decisions to the health care agency and to the client. Acting as a conduit of information between the insurance company and the other two parties adds another dimension of complexity to the case manager's advocacy role. This also increases the possibility of role conflict or confusion, particularly if the client perceives that the case manager is taking the insurance company's side. If this occurs, the case manager's relationship with the client is jeopardized, which, in turn, undermines the case manager's ability to meet set goals. On the contrary, if the case manager practices in the payer-based setting, the client's interests continue to be the case manager's top priority despite the need to also apply the payer's administrative procedures.
To avoid role conflict and confusion, case managers must execute their advocacy behaviors based on the principle of “client-centeredness,” that is, putting clients' interests first. To comply with this principle, the case manager must pay close attention to the relationship between “doing the right thing” and communicating the insurance company's decision to the client. The case manager can accomplish this by maintaining knowledge of the client's wishes and interests especially as they relate to the client's medical condition; examine whether these interests are appropriate and realistic; and incorporate them in the discussion the case manager has with the client regarding the insurance company's reimbursement or authorization decisions. It is also advisable for the case manager to have an alternate plan of care if the client's interests and the insurance company's decisions are in conflict before the case manager communicates with the client.
Advocacy is integral to case management and is applied at every step of the health care delivery process. Although the strategies employed and the tasks undertaken may differ, the focus on the client is a unifying factor for advocacy. To be effective advocates, case managers must maintain such focus in all of their various roles and responsibilities. They also must possess appropriate role-related skills and knowledge that allow them to successfully serve their clients/support systems. Acquiring the necessary knowledge and skills in client advocacy and employing strategies that facilitate advocacy while executing their roles as described in this article will assist them in becoming the desirable advocates for the clients they serve. Ultimately, they are able to impact performance of health care organizations and systems on the IHI's Triple Aim: better individual health and care experience, better population health, and affordable care. More specifically and at the individual client level, case management advocacy ensures that clients access the services they need at the time they need them and in a context of their choosing. Part II of this article focuses specifically on the required competencies of case managers in advocacy, describes a client advocacy model for use by case managers, and shares important strategies that help facilitate the case manager's advocacy role.