CMSA's Integrated Case Management

Kathleen Fraser, MSN, MHA, RN-BC, CCM, CRRN, served on the Case Management Society of America’s (CMSA’s) National Board of Directors, holding four positions, the last being the office of national president (from 2014 through 2016), then became CMSA’s national executive director immediately following her presidency. She also became a master trainer for CMSA’s Integrated Case Management program, which led to this manual. Rebecca Perez, MSN, RN, CCM, FCM is an experienced Registered Nurse with a master's degree in nursing, is a Certified Case Manager, a member of the Omega Gamma Chapter of Sigma Theta Tau International Nursing Honor Society, Capella University National Society of Leadership and Success, and a member of the National Quality Forum Leadership Consortium. Her most recent works are primary author for Case Management Society of America Integrated Case Management: A manual for Case Managers by Case Managers, Second Edition, CMSA's Case Management Adherence Guide 2020, CMSA's Case Management Adherence and Transition of Care Guide for Clostridiodes difficile, and CMSA's Case Management Adherence and Transitions of Care Guide for Hepatic Encephalopathy. She is the author of numerous professional articles and resources for CMSA, and speaker on case management topics. She is the Senior Manager of Education for CMSA and Executive Director for the Case Management Society Foundation. She was recently awarded a Fellow in Case Management designation. Corine Latour, PhD, RN, is the director of the School of Nursing at the University of Applied Sciences, Amsterdam, Netherlands. She is an associate professor for integrated psychiatric and somatic care at the university and is a contributor to the development of integrated case management in partnership with the Case Management Society of America (CMSA).

Contents


Foreword by Mary McLaughlin Davis, DNP, MSN, ACNS-BC, NEA-BC, CCM


Preface


Acknowledgments


PART I: Introduction to Integrated Case Management and Its Models


1. The Evolution of Case Management and the Professional Case Manager


2. Mechanics of Integrated Case Management, Health Complexity, and Integration Between Behavioral Health and Physical Health


3. Global Models of Integrated Case Management


PART II: Assessment of Patient Populations Using Integrated Case Management


4. Assessing the Adult Patient Through Application of the Integrated Case Management Complexity Assessment Grid


5. Assessing the Pediatric Patient Using the Integrated Case Management Complexity Assessment Grid


6. Common Physical and Mental Health Conditions


PART III: Strategies for Optimal Patient Communication and Outcomes With Integrated Case Management


7. Addressing Social Determinants: Clinical Versus Nonclinical Issues


8. Motivational Interviewing and Shared Decision Making for the Medically Complex Patient and Family Caregiver


PART IV: Transitions of Care and Accreditation Care in Integrated Case Management


9. Interdisciplinary Care Teams Fostering Successful Transitions of Care


10. Professional Case Management Accreditation Care Coordination Measures and Outcomes


Appendix A. CMSA’s Definition of Professional Case Management and the Standards of Professional Case Management Practice


Appendix B. Interdisciplinary Case Management Team


Appendix C. Triggers for Integrated Case Management Intervention


Appendix D. Adult Integrated Case Management Complexity Grid


Appendix E. Adult Integrated Case Management Complexity Grid Elements and Rating Scales


Appendix F. Pediatric Integrated Case Management Complexity Grid


Appendix G. Pediatric Integrated Case Management Complexity Grid Elements and Rating Scales


Appendix H. ICM-CAG Scoring Sheet


Appendix I. PIM-CAG Scoring Sheet


Appendix J. Definition of Terms


Appendix K. Abbreviations


Appendix L. Suggested Scripted Interview Questions


Index