Health care professionals, including case managers, are active participants in and leaders of the efforts organizations undertake to address the challenges of the Triple Aim of the Institute for Healthcare Improvement (IHI): enhance the client experience of care, improve the care outcomes of clients and populations, and reduce costs of care and services (IHI, 2016). They also advance the six fundamental aims of health care identified by the Institute of Medicine (IOM) in its 2001 report “Crossing the Quality Chasm”: health care must be safe, effective, patient-centered, efficient, equitable, and timely (IOM, 2001). Case managers play an essential role in meeting these demands, especially through client advocacy that is integral to the success of the case management interventions and decisions. In this regard, case managers approach advocacy as a central focus of their relationships with the clients/support systems (partnership). Key factors of success in these relationships are characteristic of case management advocacy: client-centeredness, timely access to necessary care, honoring client's choice and self-determined care goals, and respect for client autonomy and independence. Part I of this two-part article described these characteristics at length (Tahan, 2016).
Case management programs today consist of missions, goals, and initiatives that require collaboration across care settings and health care providers. This is drastically different from the traditional focus on an individual client's episode of care (e.g., emergency department or clinic visit, hospitalization) or the walls of a single organization or care setting (e.g., hospital, subacute rehabilitation facility). Success in achieving desired improvement in the provision of health care services and clients' experience of care requires breaking down the traditional barriers and pursuit of strategic collaborations across these old boundaries. It also demands that case managers advocate for their clients every step of the way and beyond any one particular episode of care or provider, especially when they are involved in care coordination, transitions of care, interdisciplinary collaboration, and provision of timely access to and client-centered care for clients and their support systems. Case management leaders have not yet fully recognized the importance of client advocacy as a priority role of the case manager. And those who have, lack the use of training, education, and competency development programs that aim to prepare the case manager for success in this role. This article addresses this gap and provides guidance for the establishment of such programs.
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 case managers and their leaders to examine the state of advocacy in their case management programs, identify opportunities for advancement, and use the content of this two-part article to bring their programs to state-of-the-art advocacy practice. Part I explored the ethical theories and principles of advocacy, the perception of case management-related professional organizations of advocacy, and types of advocacy (Tahan, 2016). 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.
It is important to note that the author published a version of this article initially in 2005 (Tahan, 2005) the content of which is mostly reflected in Part I of this two-part series. Over a decade later, although the practice of advocacy in case management has improved and professional organizations such as the Case Management Society of America (CMSA) and Commission for Case Manager Certification (CCMC) have identified advocacy as a necessary ethical principle (CCMC, 2015) and practice standard (CMSA, 2010), not much has been published about the context of advocacy and the roles of case managers; nor about the foundational knowledge, skills, and competencies required for successful advocacy (Tahan, 2016).
The IOM notes that advancing its six aims of improving health care for clients and their support systems requires the involvement and commitment of all stakeholders (IOM, 2001). Of these are the case managers who, through their roles as client advocates, are able to engage clients and their support systems in their own health and health care (i.e., self-management). To provide quality, cutting-edge, safe, effective, efficient, timely, equitable, and client-centered health care services to clients/support systems, case managers must apply advocacy as an integral element of care provision and at every step of the case management process. They also must develop respectful and trusting case manager–client relationships that respect the client's autonomy, independence, and right to self-determination. Moreover, they must support the client's culture, including values, belief system, preferences, and interests. Case managers then as advocates are able to advocate for their clients, while advancing the IOM's six aims. For example, they may engage in specific activities that support each of the aims such as the following:
- Safety: Prevention of harm and advocating for what is in the client's best interest.
- Effectiveness: Establish care goals that are relevant to client's health condition, aim to enhance care outcomes, and are based on informed and shared decision-making where the client's right to choice and self-determination is respected and valued.
- Client-centeredness: Ensuring convenient and well-coordinated engagement of a client in own health and health care needs, preferences, and values. This includes explicit and partnered determination of care options while matching them to client goals.
- Timeliness: Coordinating appropriate access to services and resources at the time needed and in the most effective care setting and with best health care provider. Special focus here on preventing delays in care that may compromise client's safety, care quality, and outcomes.
- Efficiency: Implementing a proactive approach to care that engages the client in the development of necessary self-care and self-management knowledge and skills. Ultimately such level of engagement empowers the client to be accountable for own health and reduces avoidable and unnecessary access to services.
- Equity: Provision of case management services that are fair and not based on client's socioeconomic background, gender, race, ethnicity, education, health literacy, and degree of adherence to care regimen. Such context prevents health disparities and promotes a just approach for the distribution of resources.
The Client Advocacy Model
The majority of case managers' advocacy acts occur at the individual client level while they care for their clients and clients' support systems. These acts are at the heart of the case manager–client/support system relationship. Despite this reality, case managers may also engage in advocacy acts at the organizational, service, community, or population levels, however, to a much lesser degree. Comparatively speaking, even a smaller number of case managers engage in advocacy at the global level, and those who do, mostly engage in some form of social, public, and health policy. Considering that the reality of case managers' advocacy behaviors is primarily at the individual level, it is important for case managers to be comfortable, confident, and competent in framing their approach to advocacy by applying a client-based model. This model empowers the client and is based on the fundamental view that the client determines and communicates own advocacy interests and the case manager facilitates the client's ability to achieve them. In this model, the client is the source of control and is an active participant in designing the focus of advocacy and how to attain self-designed desires. Such approach demonstrates respect for client's autonomy, independence, right to choice, and self-determination.
Client advocacy is an integral element of a case manager's practice and is considered a critical function. In this regard, case managers, for example, assist clients in gaining access to necessary health care services, to speak for themselves and own their voice, advocate for their rights, participate in making decisions about their care options, gain awareness of their health insurance benefits, and become empowered as owners of their health status and well-being. To better understand how advocacy works in a case manager's practice, let us consider the theoretical framework of “client-advocacy” depicted in Figure 1.
The client advocacy model is an interpersonal practice approach and consists of three main components: technical services, personal service, and care experience. This client advocacy model is generic in nature and theoretical and allows case managers to consistently apply it as a foundation or context for the way they care for their clients while considering the characteristics of the individual client situation. Each case manager–client relationship and care context is affected by the technical skills and competencies of the case manager, and the quality of the personal service demonstrated in the relationship. Both components then affect the client's experience of care, whether optimal or suboptimal. Case managers can easily apply the client advocacy model in their day-to-day practice to ultimately contribute to the care experience of the individual client. Such applications enhance the client's health condition and associated outcomes: quality, safety, experience, and affordability. A fundamental driver in this model is the belief in a humanistic view of the client the case manager shows in the context of a supportive interpersonal relationship with the client.
The technical services component of this client advocacy model focuses on the quality and safety of the case management services case managers provide to clients and their support systems. The skills, knowledge, and competencies of the case managers affect these services and therefore their associated outcomes. A skilled, knowledgeable, and competent case manager is better able to ensure that each client receives the right services, in the right quantity, at the right time, by the right provider, and in the right level of care in accordance with the client's heath situation and care setting. Advocating for such services ensures optimal quality and enhances the client's safety. Through effective case manager–client relationship, the case manager is able to advocate for the provision of timely and necessary care and range of services that are based on the client's goals, needs, interests, and beliefs (i.e., client-centric care provision). The case manager is also able to respect the client's decisions regarding care options. In addition, the competent case manager as an advocate ensures that the client has the information necessary to make informed decisions, resolve problems, manage concerns, and voice own opinions regarding the plan of care and case management services.
The personal service component of the client advocacy model addresses the characteristics of the relationship the case manager establishes with the client/support system. A case manager who is an effective client advocate is someone who establishes a trusting, respectful, transparent, healing, and open relationship. The client evaluates the quality of the personal service experienced in the client–case manager relationship based on a number of questions relevant to advocacy. For example, does the case manager respect the client's right to choice, autonomy, self-determination, and confidentiality? Is the relationship free of judgment? Does the case manager approach the client/family with compassion, positive attitude, empathy, and with concern for what is in their best interest? Does the relationship empower the client and enhance his or her self-confidence and informed decision-making abilities? Does it adhere to ethical principles and professional codes of conduct? And most importantly, does the relationship demonstrate trust, respect, veracity, and transparency?
The personal service component of client advocacy also focuses on the acts of advocacy as a partnership between the case manager and the client, almost like having an “unwritten contract” (Daniels, 2009, p. 50) that requires the case manager to operate with the client/support system as the top priority, source of control, and the most important individuals in a situation. Case managers and clients engage in a one-to-one relationship and the quality of this partnership is driven by the personal service the case manager creates and offers the client. Depending on the client's situation, the relationship may be limited to a health encounter or an episode of care such as in the case of hospital-based case management. This allows for a short-term advocacy. In this case, it is necessary for the case manager to alert the client/support system of need to terminate case management services and ensure that the client is in agreement, ready, and will be safe after service termination and closure of the relationship. These are integral characteristics of effective client advocacy.
In some care contexts or practice settings, the case manager–client relationship extends beyond one encounter or episode of care. Examples are the payer-based and primary care case management settings where case managers support clients on an ongoing and longitudinal basis, one care encounter after another and sometimes in-between encounters. Client advocacy in these settings is of the long-term type and extends as long as the client–case manager relationship exists, and the better the quality of the personal service is the more rewarding the client's care experience becomes. Optimal personal service the clients/support systems experience is demonstrative of the case manager's knowledge of social, public, and health policy determinants, having a sense of loyalty and responsiveness to clients and their needs, capacity to enable clients to be fully engaged in their own health, and ability to ensure fair and equal treatment for all.
The technical services and personal service components of the client advocacy model are interrelated. One affects the other and both are usually simultaneously in action, whether the case manager is developing a plan of care for a client, interviewing a client/support system to understand his or her interests and needs, or discussing a client's care and services with other providers or the payer representative. Through the case management process and the individualized client–case manager relationship, the case manager demonstrates knowledge of health care services and resources, skills in execution and brokering of services, and competencies in the provision of necessary, appropriate, quality, safe, ethical, and equitable care. The context of such service delivery is the personal experience of the client, which also depends on the quality of the case manager–client relationship. Ultimately, advocacy as an integral element of case management practice and desirable characteristic of the client–case manager relationship affects the overall client's care experience that is the third component of the case management client advocacy model.
The care experience component of the model focuses on how advocacy contributes to the quality and safety of the case management services provided to clients and their perception of their experience during and after care provision. Improving health and health care quality can occur only if all stakeholders (i.e., client, client's support system, payer, and provider) are collaborating, cooperating, and in agreement with and actively involved in achieving such a goal. The case manager, for the purpose of client advocacy, is able to bring these stakeholders together based on the needs and for the benefit of the individual client. This ultimately influences the client's outcomes: quality, safety, cost, and perception of the care experience. As a result, the advocacy actions case managers implement at the individual client level and for one client at a time culminate in advocacy at a broader level (e.g., organization, community, and population). Such level of advocacy is then likely to advance the goals of, and performance on, the value based purchasing (VBP) program, IHI's Triple Aim, and the National Quality Strategy. Therefore, case managers as client advocates are able to impact the broader goals of better individual health and care experience, better population health, and lower cost or affordable health care. More specifically, case managers are able to advance the six aims of the National Quality Strategy through their efforts of individual client advocacy, including the following actions:
- Provision of client-centered, reliable, accessible, and safe case management and health care services.
- Addressing the client's behavioral, social, and environmental determinants of health.
- Reducing the cost of health care services for the individual client/support system through elimination of duplication, fragmentation, and barriers to or delays in care.
- Making care safer by preventing harm caused in the suboptimal delivery of care.
- Ensuring that each client/support system is engaged as a partner in own care.
- Promoting effective communication, transparency, ongoing flow of information, and coordination of care among the various members of the interdisciplinary care team, including the client/support system.
- Ensuring the delivery of equitable, just, and culturally sensitive health care services for clients and their support systems.
Advocacy and Client Engagement
One of the ultimate goals of the case manager–client advocacy relationship is transitioning the client from a state of detachment to full engagement in own health. The case manager achieves this by intentionally shifting the client's state of reluctance and apprehension to that of comfort and empowerment in assuming responsibility and accountability for own health and health care. This transition is in the client's best interest and results in the client experiencing better health outcomes and lower costs by avoiding unnecessary access to health care services and preventing the provision of suboptimal services. A client who feels empowered is more likely to be actively engaged in the management of own health. The engaged client is then able to assume responsibility for self-care and self-management, make informed decisions about care options, and share own personal opinions about services and resources. Case managers use advocacy in a strategic and intentional manner to bring their clients to a state of full engagement and control over own health care. They may achieve this through a stepwise approach such as the one described in Figure 2: stages of client's engagement. It is important to recognize that effective case managers are those who start their advocacy role from the first time they encounter their client/support system.
Client engagement means assuming an active role in staying healthy or preventing deterioration in condition. It is the responsible involvement of individuals in own care, or others they designate to engage on their behalf, with the goal that they make well-informed decisions about their health and health care services, take action to support these decisions, and demonstrate accountability in self-management. Case managers as advocates empower their clients to be engaged in their health through imparting knowledge and understanding of illness, counseling regarding fears and concerns, and equipping them with the necessary information for effective shared decision making, self-efficacy, and self-management.
Clients may transition to full engagement through nine stages (see Figure 2). Case managers use advocacy as a key strategy to facilitate this transition. Throughout the stages, case managers emphasize the importance of clients defining their own needs for advocacy and then take direct actions to fulfill these needs with the support of the case managers. The nine stages and their related case management advocacy actions are as follows:
- Raising awareness: Case managers share essential information with clients about their health conditions and their perception of the clients' states of engagement. They support their clients in acknowledging the presence of illness and the state of health-related behaviors. Case managers remain attuned to the client's ability to perceive what is shared and the feelings expressed about or responses to the situation while maintaining a supportive and nonjudgmental attitude. Case managers use advocacy when raising awareness to bring their clients to accept that a serious situation exists and that it is in their best interest to do something about it. Throughout the awareness conversation, case managers remain supportive of the client, meet their duty of respecting the client's dignity and autonomy, and respect the client's rights.
- Doing for: During the time case managers are raising the awareness of their clients to their health conditions, they continue their advocacy actions by “doing for” the patient. This is important to prevent the clients from experiencing unsafe situations or suboptimal care. It is also reflective of case managers representing those who are unable to represent themselves. An example is providing a client with information about heart failure and securing a scale for the client to use for monitoring body weight regardless whether the client asked for such. Case managers may “do for” their clients while educating them about their conditions and needs, clarifying situations for them, and simplifying what they may perceive as complex and vague. Throughout this stage, case managers maintain objectivity, refrain from disapproving undesirable behaviors their clients may demonstrate, and intervene on behalf of the clients as warranted.
- Counseling: Case managers use counseling as an act of advocacy to gain a better understanding of where the clients are at with acknowledging their health conditions, what fears and/or anxieties they may be experiencing, and what type of support they may value most. At this stage, case managers offer their clients with professional guidance to assist them in resolving emotional problems and addressing the concerns or conflicts that may have arisen. They also guide them in making informed decisions and taking action toward engagement. During this stage, case managers may use motivational interviewing to assist their clients in uncovering barriers for engagement and self-management, and to verbalize any sensitive information that may be hindering their progress.
- Doing together: Here case managers assist clients in their attempts at taking care of their own health condition. For example, together the case manager and the client may practice self-injection of insulin. The case manager may first demonstrate the behavior to the client and then ask the client to repeat it. During the practice, the case manager imparts specific knowledge to the client so that the client begins to develop a level of comfort with the behavior and familiarity with the technical aspects of self-care. Although the client may not be able to assume full engagement in own health care yet, the client begins to move away from detachment and reluctance and more toward engagement and empowerment. Case managers use teachback to examine the client's degree of understanding and comfort with self-management and to determine areas for improvement and further emphasis.
- Coaching: Case managers shift from “doing with” to supporting clients in becoming the owners of their health and by demonstrating effective self-management. Through coaching, case managers support their clients in developing necessary skills and abilities and help them deal with issues and challenges before they become major problems. Coaching as an act of advocacy may take place as a conversation between case managers and their clients. Clients perceive coaching to be a positive and rewarding approach to self-management when case managers help them explore their own care goals and then achieve them. Case managers at this phase act as “guides” safeguarding safety while clients act as the “doers.”
- Doing independently: Through coaching and continued support, case managers assist their clients to reach to a state of independence in performing self-care and self-management activities. In this phase, the clients are engaged, empowered, and comfortable in “doing for themselves.” They also are able to seek case managers as needed. The clients behave as well-informed individuals and are aware of their health condition, the importance of their health decisions (self-determination), and expectation of adherence to care regimen (autonomy).
- Ownership: Here clients demonstrate rights and duty toward taking care of their own health and health care (autonomy and independence). They are responsible and accountable for making decisions, seeking information or support when they feel the need to, and voice their opinions about their options, needs, and interests (self-determination and right to choice). Case managers continue to coach and support their clients as they develop their skills and abilities for self-care and self-management and reward effective performance. They also step back and wait for their clients to ask for their assistance rather than force their support on the clients. Despite the “hands-off”-like approach to caring and advocating for their clients, case managers continue to ensure that their clients are safe, receiving optimal care, and their health outcomes are improving. Ultimately, case managers intervene when situations are questionable and to prevent suboptimal or unsafe care provision.
- Mastery: At this stage, clients demonstrate grasp over their own health condition, interact in a knowledgeable manner, make well-informed decisions, and voice what is in their best interest. They also assume full responsibility for shared decision-making and the advancement of the client–case manager relationship to a true partnership. Clients act in a confident manner and free of self-doubt, actively purse information instead of being passive recipients of it, and demonstrate necessary skills and knowledge in self-management. Case managers in this phase continue to support their clients and advocate for them by applying similar strategies as those of the ownership phase.
- Maintenance: Case managers monitor the ability of their clients to conserve the mastery they achieved over their health and health care. This is important for ensuring that clients continue to experience safe health condition and quality outcomes. In this stage, clients are feeling empowered and consistent in demonstrating full engagement in their health needs and care.
The nine stages of engagement guide the transition of clients to a state of full engagement that is characterized by clients taking effective action to obtain the greatest benefit from the health care services available to them. This state is also distinguished by clients' careful consideration of the essential information, empowerment, and counseling provided to them by case managers in assuming accountability for self-management. In addition, this state of engagement is alive when clients identify their own advocacy priorities and play active roles in addressing them, are not hesitant to voice their needs, preferences, abilities, and concerns in order to prevent and manage barriers to engagement such as fear and anxiety. It is also optimal when case managers stay away from judging or criticizing their clients, no matter at which stage of engagement they are. The stages of client engagement are most effective when the case manager's advocacy actions primarily focus on the behaviors of the clients that are critical and proximal to health outcomes, rather than the actions of the health care professionals or organizational policies that sometimes may act as barriers to advocacy.
It is natural for a client's health state to change over time. Accordingly, the client's health care needs also change. Therefore, the case manager's advocacy efforts must evolve to meet the client's changing needs and to ensure that the client's state of empowerment and engagement continues to be effective and appropriate, despite the changing nature of the client's health condition and needs. It is also necessary for the case manager to evaluate the state of the client engagement on an ongoing basis but especially at critical junctures when there is an acute or significant change in the client's health and/or needs that may have affected the degree of the client's engagement in self-management. Based on the findings of this evaluation, the case manager then determines the impact of the change and the degree of engagement the client demonstrates. Here the case manager identifies the stage of engagement the client is at and whether the stage is different from or same as before. Thereafter, the case manager supports the client and implements essential advocacy acts that are warranted to bring the client back to the maintenance stage of engagement.
Case managers succeed in bringing their clients to a state of empowerment and full engagement by effectively managing a number of factors that are known to influence clients' health behaviors. These factors are complex and include characteristics of the individual client, culture and health condition, care provider, and care setting (see Table 1). By acknowledging these characteristics and carefully considering them when deciding about the best essential advocacy action(s) for an individual client, only then case managers are able to advance the client's behaviors that pertain to care navigation, information-seeking, informed decision-making, getting access to resources, and development of self-management skills, therefore, engagement in own health and health care.
Strategies for Case Managers' Advocacy
Case managers in any care setting often act as members of “collaborative interdisciplinary care teams” usually composed of providers (i.e., physicians, nurse practitioners, and physician assistants), case managers, registered nurses, social workers, physical and occupational therapists, utilization managers, psychologists, pharmacists, and other professionals and paraprofessionals (e.g., community health workers, health educators, navigators, and client advocates). Skillful and agile case managers apply several advocacy strategies in their daily interactions with clients, payers, and collaborative team members and while navigating the complex health care system. A common goal when applying any of the strategies is facilitating the clients' access to required services and resources. A primary advocacy strategy, commonly used by case managers in care delivery, is “doing the right thing.” It is directly linked to the best interest of the client. Doing the right thing can be described as the delivery of care and services that are proper, indicated by the client's condition, and preferred by the client and client's support system. It is optimal in that care is provided in the most appropriate care setting and by the provider of choice, and that it meets the wishes and preferences of the client. This protects the client's autonomy, right to choice, self-determination, and informed decision making.
Doing the right thing also means that case managers ensure that health care professionals provide clients with the type of services they need based on their medical and socioeconomic condition and including the necessary tests, procedures, and treatments, and that they are completed expeditiously and safely. Importantly however, doing the right thing is seen by case managers as a function of quality of care, safety, continuity of care, common goals, collaboration, and teamwork among the various disciplines involved in the care of the individual client/support system.
Another strategy that is closely related to advocacy, and that is aligned with doing the right thing, is care coordination. It is defined as a comprehensive process of planning, delivering, coordinating, and monitoring of health care services, while meeting the needs of the clients and their support systems, ensuring cost-effectiveness and safe, quality care. The emphasis in this strategy is on the client, similar to “doing the right thing.” Case managers coordinate the health care services needed by their clients across the continuum of care and diverse providers. They also focus on meeting the clients' physical, emotional, psychological, spiritual, financial, and cultural needs through the coordination of care activities and communication among the various care providers. Care coordination-related advocacy activities encompass assisting clients to return to their baseline lifestyle and health condition or getting to the highest level of function that they can get to. Such activities are client-centered, directed, and focused. Integral to care coordination is the emphasis on the clients defining their needs for advocacy based on informed and shared decision-making, and then case managers as client advocates support their clients in taking direct action toward fulfilling the goals (i.e., client empowerment and engagement).
When ethical dilemmas or disagreements concerning client care and treatment options arise, case managers may apply the “case conferencing” method as a strategy in resolving the ethical and other concerns that facilitates clients' ability for informed and shared decision-making. Case conferencing is relevant to advocacy because it is used as a conflict-resolution process and a method to educate the client and/or client's support system about care and to discuss decisions such as stopping treatment, withdrawal of life support, and do-not-resuscitate status. Case conferencing is also useful in situations when clients and their support systems are unclear about diagnosis, prognosis, length of treatment, or the transition/disposition plan. Decisions made during case conferences are resolutions to issues at hand and are to the clients' satisfaction. Acknowledging and addressing the needs of the clients and their support systems reflect the case manager's duty as an advocate. This advocacy approach allows clients/support systems to voice their opinions (i.e., having a voice and defining an existing problem from their own perspective), and emphasizes the role of case managers as advocates in assisting them in addressing their self-defined needs (i.e., client-centered and culturally competent care). It also provides clients with a concrete opportunity to identify alternate and creative solutions to the issues or concerns rather than just accepting the status quo. This also promotes advocacy as an active event rather than as a passive event, that is, clients owning the resolution of concerns in collaboration with the case managers to meet their self-defined desires.
Outcomes management is a strategy that is aligned with advocacy because of its intense client focus. Outcomes management involves tracking, monitoring, and data analysis regarding care delivery, patient care outcomes, delays in treatments, tests and procedures, risk management concerns, and reimbursement issues and denials. Outcomes management is necessary for evaluating the consequences of care delivery and allows the collaborative interdisciplinary care team to examine whether the needs of the clients are met and to what extent (i.e., quality of care, safety, and care experience). The process of determining outcomes begins with reviewing the client's record, to collect data such as clinical care outcome indicators, delays in tests or procedures, and risk management issues. Through outcomes management, case managers ensure that the clients gain access to necessary resources and that their needs are met and in a timely fashion. Through outcomes management, case managers as advocates can focus on assessing the impact of their actions on the well-being of clients and their support systems, development of self-management skills (i.e., engagement), understanding of health conditions and plans of care, and ultimately empowerment.
Advocacy strategies case managers employ in their daily practice are not limited only to doing the right thing, care coordination, case conferencing, and outcomes monitoring. Other examples that advance their roles as client advocates are summarized later.
- Communicating among team members, with the client and client's support system, and with the members of internal (health care agency-based) and external (outside the health care agency such as transportation and durable medical equipment vendors) teams to discuss care, services, and related issues. A special focus of advocacy here is “respect for the client wishes and choices” and “empowering the client to voice own thoughts.”
- Teaching to ensure that the client and other members of the health care team are kept informed and knowledgeable of health insurance or managed care regulations and statutes, the decision-making processes of the insurance companies, and the procedures of denials and appeals. Teaching also focuses on increasing the client's knowledge of their health insurance benefits, plan of care, how to change or reduce illness-related risk factors, how to navigate the health care system, when to engage in follow-up care, and how to care for self while at home.
- Resolving Disagreements that might arise between members of the different teams involved in a client's care, between themselves and the client, or between the client and members of the client's support system. The activity focuses primarily on client's safety and good health and promotes client's autonomy, self-determination, and shared decision-making.
- Brokering of Services to ensure that appropriate care options and resources are arranged for and made available to the client while in the hospital setting (or during an episode of illness), upon or at the time of discharge, or after discharge and while in the community. This activity aims to ensure the client's access to the health and human services they need or are interested in. When brokering services for their clients, case managers encourage clients to voice their desires and preferences and operate based on already-established mutually agreed-upon goals.
- Obtaining Informed Consent from the client for treatments to be provided and tests and procedures to be completed. It is also necessary to confirm that the clients grant the case manager permission to appeal on their behalf the decisions made by insurance companies to deny services or reimbursement for care rendered. The case manager facilitates the clients' informed decision and respects their right to choice.
- Supporting, that is, to provide clients and their families with emotional support and counseling as needed to reduce their anxiety and apprehension during the episode of illness and the course of treatment. It may also mean working with the client and support system to realize that they have to assume responsibility for their care and related decisions. This activity allows case managers to assist clients in their efforts to navigate the complex health care system by developing needed skills in self-management, acquiring necessary knowledge, and clarifying areas of confusion.
- Appealing denials according to stipulations of contractual agreements between the health care agency/provider and the insurance company (payer). This is made in an effort to ensure that the agency receives reimbursement for care provided and that the clients receive the care and services needed as necessitated by their medical and health conditions. A major purpose of advocacy in appealing denials is ensuring the client's access to needed services.
- Going above and beyond to ensure that the clients' needs, both direct and indirect, are met. This activity focuses on looking beyond the obvious care needs. For example, if a client is hospitalized and has a pet left alone at home, in addition to ensuring that the client's medical needs are met, the case manager devises a safe plan for the pet as well. This also includes activities the case manager may take to ensure that the client's experience of care is optimal. By going above and beyond, case managers demonstrate advocacy for the provision of culturally competent and client-centered care. This also provides the client to articulate self-defined goals.
- Establishing relationships with varied members of the health care team internal and external to the health care agency and as necessary for better delivery of care and services. This is important for effective coordination and management of care and outcomes. Establishing a trusting case manager–client relationship enhances the case manager's ability to advocate effectively with the members of the health care team on behalf on the client.
Negotiation and Advocacy: Maintaining a Delicate Balance
Case managers face the challenge of balancing the competing priorities and pressures brought upon by the clients, providers, payers, and fellow health care team members. As coordinators and facilitators of care, they are able to acquire an understanding of the competing priorities and interests of the different parties involved in a given situation and the associated demands. This is necessary to effectively advocate for the client. The case manager's role is executed within the context of collaborative case management approach to the delivery of health care services, keeping the client and client's support system at the center and as a top priority.
Case managers use negotiation as a desired method to acknowledge the demands of the various parties, resolve or prevent conflict, and pursue desirable results. The main purpose of applying negotiation is the desire to “maintain a delicate balance” of the competing priorities and demands of the various involved parties. Negotiation is a useful tool in advocacy because it facilitates and supports the making of agreements among the different parties involved in the delivery of health care services. It also is most important when agreements are not freely forthcoming. The main percept of negotiation in case management advocacy is that it aims to reach an agreement/final decision where each party involved feels that the result is fair, equitable, free of bias, and satisfactory. Although such outcomes are not always possible, case managers must exert every effort and employ negotiation tactics that reach fair and equitable agreements in the end (Frankel & Gelman, 1998), and outcomes that reflect what is in the best interest of their clients/support systems.
When faced with an advocacy situation that requires negotiation such as conflict regarding treatment options, case managers conduct an evaluation of the situation. Based on the evaluation, they identify which party opposes what is in the best interest of the client/support system. Keeping the client and support system at the center of advocacy and health care delivery provides the necessary focal point and helps ensure that case managers are “doing the right thing” and protecting “what is in the best interest of the client.” From this perspective, case managers use negotiation as an advocacy tactic to resolve conflict, balance the outcomes, and enhance the chance for a win–win resolution.
To illustrate, consider a situation in which an insurance company denies treatment that a physician, hospital, and health care team feel is necessary. The case manager representing the hospital and the physician stands by the client and negotiates with the insurance company (payer) representative, attempts to influence a favorable change in position; that is, authorization of the treatment that implies reimbursement for services rendered. If the efforts fail, the case manager may seek the assistance of the physician or other members of the staff at the hospital to negotiate with the insurance company the approval of the treatment. It is necessary for case managers to know what they want to achieve (i.e., clarity of problem and purpose) and advocate for before engaging in negotiation. It is also as essential for them to understand the needs of the other parties, including the client/support system, the insurer/payer, and the other providers of care involved in the situation.
In a win–win situation, an agreement is reached and all parties-–the client, insurance company, physician, hospital, and the team-–are happy. In a win–lose situation, either the client or the insurance company loses. If the losing party were the client, the case manager and the team would not give up; rather, they negotiate further on behalf of the client to reach a satisfactory resolution with the insurance company. Throughout negotiation, case managers maintain a constant awareness of the goals of care delivery, namely, efficient and appropriate use of resources and client-focused care. They also keep mindful of the needs of the health care agency, including the potential financial impact of the outcomes (desired and actual).
Facilitators and Challenges of Client Advocacy
Experts and leaders may agree that client advocacy is not only an ethical and legal expectation, but it also is a philosophical foundation and guiding principle for case management practice. Advocacy as an integral component of every aspect of the case manager's role, regardless of care setting and professional discipline, is not a choice; it is rather an ideal and a moral obligation. Case managers apply advocacy as a necessary strategy to build effective and respectful relationships with clients and their support systems and to serve as liaisons between them and the complex health care system, especially when they attempt to navigate it seeking timely access to care.
The case manager's role already presents some challenges, often because of its primary focus on the provision of safe, quality, timely, and affordable care while ensuring a client's experience of care that is optimal and free of any conflicts, delays, or disappointments. Advocacy adds to such challenge, especially because case managers usually advocate on behalf of those who feel powerless, voiceless, less fortunate, vulnerable, victimized, and resigned to the status quo. Failure to effectively advocate for these clients may further compromise their safety, rights, welfare, deciding on care options, self-management, and ultimately health and care outcomes.
It is an expectation that case managers face some risks and obstacles when advocating for clients and their support systems. It is also important to acknowledge that certain characteristics in the context of case management practice may facilitate successful client advocacy. Table 2 lists examples of facilitators and obstacles in client advocacy from the perspectives of both the case manager and the client and/or support system.
Establishing a trusting, respectful, functional, and authentic case manager–client relationship is fundamental to effective advocacy. Such relationship is characterized by interacting with the client as the case manager's number one priority, understanding the client's goals in order to successfully act on their behalf, and projecting the belief that the client is capable of self-identifying own needs and desires and is empowered enough to be actively engaged in self-care and own health. Other facilitators of client advocacy are availability of a code of ethics and professional conduct; assuming accountability for the role of advocate; demonstrating knowledge, skills, and competence in this role; and dealing with the client as an active participant in advocacy rather than as a passive recipient of it. In addition, client advocacy is easier to accomplish when the case manager is skilled at interprofessional practice and the development of effective and collaborative relationships with members of the interdisciplinary health care teams and other key stakeholders especially those who represent community-based resources and agencies.
One may argue that absence of the facilitators of client advocacy including those described earlier translates to barriers and challenges to developing effective client advocacy. From the case manager's vantage point, absence of a code of ethics and professional conduct to guide practice and decision making; unclear policies, procedures, and standards of care; limited time; unsupportive or missing peers and supervisors; and competing priorities all contribute to suboptimal and ineffective advocacy, which ultimately may place the client at increased risk for unsafe care and poor-quality outcomes. On the contrary, when clients and/or their support systems feel powerless, voiceless, and lacking confidence, disengaged, act in a passive manner, and resign to the status quo, they also contribute to ineffective advocacy, suboptimal care, and poor outcomes.
The health care organizational culture (and the specific culture of the individual care area or setting) is a major influencing factor of client advocacy. It may facilitate or hinder the case manager's ability to advocate for clients. For example, a culture that promotes transparency and teamwork and empowers case managers to handle client advocacy as a top priority contributes to successful advocacy and ultimately optimal clients' care experience. In contrast, a culture that breeds conflict, hierarchy, and lack of support disempowers case managers, is indecisive about the standards and procedures that relate to ethical practices, and lacks clear focus on clients' needs and preferences, challenges client advocacy, and results in disengaged and dissatisfied clients due to ineffective or completely absent client advocacy. Regardless however, if a case manager lacks professional responsibility toward client advocacy and is unable to demonstrate competencies and comfort in this role, presence of a culture conducive to the development of effective client advocacy still will not work. Case managers lacking in advocacy are unable to thoroughly use the cultural characteristics that support advocacy for the benefit of the client. Advocacy is dependent on being an integral component of professional practice, a context for the establishment of client–case manager trusting relationship, and an obligation of every case manager toward clients/support systems.
Case Manager Competencies in Client Advocacy
Client advocacy is a complex process and a key role of case managers. It demands specific skills, knowledge, and competencies from case managers to ensure that clients and their support systems receive effective advocacy and that their rights and interests are protected at all times. Advocacy efforts aim to build trusting relationships, facilitate a common understanding among those involved in care provision including the client/support system, ensure the discussion and support of the client's views and wishes, raise relevant issues on behalf of the client, protect the client's rights, autonomy, and best interest, eliminate barriers, maintain fair and equitable access to client-centered care, and effect quality and safe outcomes. These goals require astute case managers and competent client advocates, individuals with specialized skills, knowledge, and competencies. Therefore, it is necessary for case management leaders to develop and implement specific client advocacy competencies for case managers. It is important that these leaders also design and offer case managers targeted training and education programs in this area to ensure that they possess appropriate knowledge and skills in the client advocacy key role.
Client advocacy in case management practice involves identifying the actual and potential unmet needs of clients and taking action to change the circumstances that have or potentially may contribute to such deficiency. This practice is not strange to case managers; they often identify actual or potential barriers to care (i.e., delays in services) and intentionally intervene to either prevent the occurrence of the barrier or minimize its effect on the client. Because advocacy is inherent in every aspect of case management practice, a case manager is not considered a proficient or expert practitioner unless if he or she specifically demonstrates competence in client advocacy.
Case managers must possess appropriate level of skills, knowledge, and expertise in advocacy to perform their advocacy roles effectively and be taken seriously by their clients/support systems, peers, and other health care professionals. Availability of support, mentoring, and training for case managers in advocacy are an important step toward enhancing competence. To develop a program of case management competence, it is necessary to first be clear about its aims, infrastructure, processes, standards, ethical principles, and expected behaviors and outcomes. These constitute the foundational characteristics of advocacy and illuminate the expected knowledge, skills, and behaviors of case managers that are demonstrative of competence in the role of client advocate. As it is the case in the literature on competence, the program of case management advocacy competencies must consist of clearly articulated behaviors or dispositions and their requisite knowledge and skills as well as their expected outcomes (see Table 3).
Training and certification programs in client advocacy in health care are beginning to form. These enhance access of case managers to training programs and professional credentials specialized in client advocacy. One example is the Professional Patient Advocate Institute (PPAI), which aims to achieve top-quality care delivery and simplified health care navigation for clients and their support systems. PPAI focuses on the training and education of health care professionals, including case managers, as client advocates to advance their skills for effectively assisting clients and their support systems in navigating the complex health care system. These professionals may also include registered nurses, disability management specialists, physicians, pharmacists, physician assistants, psychologists, health navigators, life care planners, financial or insurance services representatives, behavioral health specialists, social workers, community health workers, and other health care professionals (PPAI, 2016). PPAI essentially promotes the professionalization of advocacy and the development of competencies in this regard. It also perceives that such advocacy results in having advocates who are able to objectively assist consumers in understanding and making sense of their health care needs. This trained and competent professional is then better able to advocate for consumers as they strive to secure their health care needs and cover their insurance and financial matters (PPAI, 2016). Moreover, this professionally trained client advocate, who may be a case manager, becomes more successful in giving consumers a voice, understanding their goals, conducting research, and providing valuable information to help them make informed decisions regarding their health care needs (PPAI, 2016).
Client advocacy competencies of case managers may consist of a variety of behavioral characteristics demonstrative of the following aspects of advocacy:
- disposition of the advocacy role;
- ethical and moral disposition;
- client support and respect for autonomy, self-determination, and right to choice;
- promotion of client empowerment and engagement;
- ensuring equity and fairness in the client's access to care and distribution of resources; and
- client-centeredness and cultural sensitivity.
Case managers who embrace the role of an advocate engage in the professional disposition of client advocacy in a manner that is integral to their daily execution of the general role of a case manager. Such performance is usually seamless. That is, there is no palpable separation between advocacy and other case management functions. Therefore, advocacy is embedded in all functions, however, to varying degrees as appropriate for the function. These case managers are also autonomous in their thinking and demonstration of advocacy. Moreover, they exhibit motivation, altruism, objectivity, transparency, generous listening, and a genuine concern for clients' well-being and betterment. Client advocacy comes natural to this type of case managers.
Case managers who are competent client advocates also exhibit knowledge, skills, and comfort in ethical and moral disposition. For example, they are aware of the codes, standards, and principles of ethics of their professional discipline and case management organizations. They also understand the value of ethical decision-making models and their benefit in ethical conflict resolution. Through their personal commitment to the “ethic of caring and compassion” and moral conduct, they are able to develop trusting relationships with their clients/support systems and engage in open and transparent communication. In addition, competent case managers with professional ethical disposition are skillful at engaging clients in self-defining their concerns and taking an active role in resolving them.
In the area of client support and respect for autonomy, self-determination, and right to choice, competent case managers approach their clients as active participants in advocacy. They engage them in exercising their rights, recognition, and endorsement of what is in their best interest, maintaining their independence, and making informed decisions, especially in voicing their wishes and articulating their preferred action plan for overcoming conflicts. An ultimate aim in this competency is the case manager's ability to create a context of care that is built on “legitimacy of clients defining their own needs, desires, and goals.”
Case managers as effective client advocates demonstrate competence in the promotion of client empowerment and engagement. They reflect such competence by educating and counseling clients about their health conditions and care options so that they adapt to living with the disease and/or limitations they are facing, and acquire the necessary knowledge and skill for self-care and self-management. They also are effective at using motivational interviewing techniques to assist clients to make informed decisions, verbalize their fears and anxieties about self-management, and identify the barriers preventing them from adapting to the limitations imposed upon them by their health conditions.
Ensuring equity and fairness in the client's access to care and distribution of resources is a competency that focuses on eliminating disparities, prevention of barriers to care, and provision of nondiscriminatory services. It also includes ability to allocate health care resources in ways that meet the preferences and needs of the clients and their support systems. In addition, this competency expects case managers to educate their clients about the range of resources available to them in their communities and arrange access to these resources where needed and is considered appropriate. Client-centeredness and cultural sensitivity are an important competency case managers demonstrate when they respect the individuality of their clients, act in ways that are free of judgment, and provide services that meet the client's cultural value and belief system.
Case managers, experts, and leaders agree that advocacy is integral to case management practice and necessary for enhancing the client experience of care, quality, safety, and outcomes. Through advocacy, case managers are able to customize provision of health care services and resources according to the client needs, culture, and values. They also are effective at establishing client–case manager healing, trusting, and respectful relationships where the client is the source of control and is empowered to voice needs and preferences. In addition, case managers promote client advocacy by ensuring that the client is engaged and able to make informed decisions. Finally, they advocate for what is in the best interest of the client by maintaining collaboration and cooperation among the various involved health care providers, keeping open and transparent communication where important information flows at all times, anticipating the client's needs, and constantly focusing on client safety and quality care outcomes. While the strategies employed and the tasks undertaken may differ from one case manager or practice setting to another, the focus on the client is a unifying factor for advocacy.
To be successful at client advocacy, case managers must demonstrate that they possess appropriate knowledge, skills, and competencies in this area. They also must be able to relate the impact of their advocacy on client care outcomes (i.e., demonstrate the value of advocacy). Case management leaders are encouraged to use the content of this two-part article and develop a strategic focus on advocacy in their case management programs, train and educate case managers in this integral role, and focus on building the case manager's competence in this essential area. Ultimately, they should be able to advance the performance of the health care organizations and systems where they practice especially in the IOM six aims of high-quality health care and IHI's Triple Aim: better individual health and care experience, better population health, and affordable care.