The Core Elements of Care Management


A half century of care management practice recognizes the enduring elements of the profession: assessment, care plan development, knowledge of benefits and resources, and advocacy. Emerging expectations regarding clinical expertise may exceed current education and experience requirements. As the population becomes more diverse, a heightened recognition of cultural humility is needed, including attention to the LGBTQ community. The role of technology in care management, client services, and products is addressed. Care management models developed to secure market share differ from the independent practice model.

Key Words:  

care management, assessment, care plan 

The role of the care manager encompasses a complex array of academic and clinical knowledge, skills, and experience. This article focuses on the most critical aspects of the role: assessment, care plan development, knowledge of benefits and resources, and advocacy.

Assessment: At the Core of the Care Management Process

The care manager is a responsive, skilled assessor of multiple domains of the client and family experience. The assessment is the heart and soul of the care management process and is driven in all aspects by a commitment to a person-centered, person-directed vision. The assessment needs to include a comprehensive review of the individual’s physical and emotional health, cognitive abilities, environment, finances, functional status, and social support system (Quinn, 1993).

The physical health assessment may take different forms depending upon the professional discipline of the care manager and the practice setting. Although expectations will differ for a social service care manager, a nurse care manager, or a care manager from another discipline, every care manager must complete a comprehensive assessment. Best practice requires an in-person, face-to-face assessment for the care manager to fully appreciate the nuances of each individual in his or her environment (Geron and Chassler, 1994).

The reality is that this home visit is not always possible: for example, during the COVID-19 pandemic, in-person visits are prohibited due to health concerns; for many care managers whose client caseloads encompass large geographic regions, making a home assessment is cost- and time-prohibitive. Despite these barriers and challenges and an acceptance of the adage, “don’t let perfect be the enemy of the good,” it is important to continue to recognize the central role of in-home assessment and to visit a client at home as part of the assessment whenever possible.

The physical health assessment should include objective and subjective data gathered at the visit. The care manager should listen intently to the client’s perception of his or her health status and medical concerns (Kathol, Perez, and Cohen, 2010). Keen observation skills can go a long way in assessing multiple aspects of physical health status; for example, shortness of breath, skin integrity, hearing and vision deficiencies can be indications of health conditions that need to be addressed.

A detailed review of the client’s prescribed and over-the-counter medications should be conducted to allow the care manager to identify duplicate medications and take note of actual and potential side effects. The medication review is an example of how care managers of various disciplines respond as appropriate to their training and expertise. A nurse care manager would accurately collect medication information and also assess for potential complications, while a social service care manager would be expected to accurately collect all data but would not necessarily be expected to assess complications. All competent care managers also collect pertinent information from the client’s medical providers to augment the assessment process.

While care manager responsibilities have remained the same, expectations of clinical expertise have skyrocketed.

The behavioral health assessment requires a complex set of professional skills to identify areas of concern and opportunities for enhancing the quality of the individual’s life. Developmental milestones including the death of a spouse or other loved one, a decline in functional abilities, and significant role changes are exceptionally relevant, as are the impact of isolation, social stigma, and discrimination. The assessment must include a thorough review of signs and symptoms of depression, anxiety, and other diagnoses, consideration of current alcohol and-or drug misuse, Alzheimer’s disease and other related dementia, and serious, persistent mental illness (Capezuti et al., 2007). Here again, the level of expertise of the individual practitioner will determine the depth and intensity of the assessment. Other sources of information such as medical and mental health providers can broaden the care manager’s understanding of the client’s circumstances and pave the way for sound care planning practice.

The past decade has seen a veritable explosion in professional attention to the social determinants of health and the role these variables play in an individual’s health status and quality of life. The Health Information and Management Systems Society (2019) asserted in its recent report on the root causes of health that a person’s ZIP code predicts more about health status than the individual’s DNA. Assessments of environment, both internal to the home and external in the community, are a frequently overlooked but critical variable in the assessment process (Cress, 2007).

Through the Eyes of a Care Manager: Meet Evelyn

The following is a description of an in-home assessment by a social service care manager. It shows how the care manager uses observation, interaction, and clinical knowledge to synthesize as much information as possible to develop an effective care plan.

Evelyn is black, a 66-year-old widow living in a third-floor, two-bedroom walk-up apartment in a low-income urban neighborhood. Overfilled garbage cans line the crumbling sidewalk. The apartment building has no elevator; the stairs and hallways are poorly lit. Evelyn knows few of her neighbors and has limited opportunity to socialize with them. She is dually eligible for Medicare and Medicaid. None of the kitchen or bathroom appliances have been updated for several decades. The apartment has no air-conditioning and Evelyn does not own a car. There are no grocery stores within walking distance of the apartment. Public transportation to medical appointments needs to be scheduled in advance and is not always reliable.

Following the premature death of her husband, Evelyn raised her two children in this apartment and is now raising her two preteen grandsons. Her daughter, the boys’ mother, has been incarcerated for two years for possession of an illegal substance in a drug-free zone. Evelyn’s medical history includes severe hypertension, debilitating arthritis, obesity, type 2 diabetes, poor vision, frequent urinary tract infections, and chronic depression. Her medical care is provided at the clinic of a local acute care hospital, but she frequently misses appointments, doesn’t always refill her numerous prescriptions, and ignores recommendations concerning weight loss. The medical system labels Evelyn as “non-compliant.” Significant aspects of the environmental assessment benefitted from the care manager’s physical presence at the property. Safe, affordable housing is an important social determinant of health.

In addition to using her observational skills, the social service case manager consulted with clinic staff to learn more about Evelyn’s physical health status. She conducted a Healthy IDEAS (Identifying Depression & Empowering Activities for Seniors) assessment and shared the results with clinic staff. During this consultation the care manager was able to tactfully remind clinic staff of the numerous complications that influence Evelyn’s ability to keep appointments, refill prescriptions, and follow through on health recommendations. The assessment interview confirmed Evelyn’s Medicare and Medicaid active status, as well as her current enrollment in the SNAP program. The lack of a responsive support system was painfully acknowledged by Evelyn during the interview. The care manager recognized that, despite her eligibility, Evelyn had never been referred to the state or federal home- and community-based services program, and an application was initiated.

When asked about her goals, Evelyn’s response was immediate, convincing and forthright: “Keep the boys safe.” Initially, there was no mention or recognition of goals associated with her own health.

Developing a comprehensive care plan is the next critical step in the process. The care planning activities must take into consideration all data, observations, and collateral information identified in the assessment. Note that Evelyn identified her own primary goal, not the care manager, physician, or anyone else. Evelyn’s care plan is broad in scope and focuses on her goal. Elements of the plan include:

  • Establish school and community contacts to include school social worker or guidance counselor, in order to identify recreational afterschool and summer programs for the boys, and to keep Evelyn abreast of school performance and behavior.
  • Consider the possibility of moving to another location with better access to grocery store, playground, and health clinic.
  • Coach and empower Evelyn to recognize the connection between her health and “keeping the boys safe.”
  • Pursue application to publicly funded home care services for assistance with laundry (two blocks from the apartment), housekeeping, food shopping, and meal preparation.
  • Arrange for services of a licensed home healthcare agency for diabetic diet instruction and related nutritional counseling.
  • Support Evelyn with the assistance of a community health worker to develop a calendar or schedule of clinic appointments, have transportation scheduled in advance, and accompany her to appointments.

Evelyn’s situation clearly illustrates the role of the care manager regarding knowledge of benefits and resources including health clinics, licensed home care agencies, school services, housing opportunities, and public home care programs. Had Evelyn not already enrolled in Medicaid and SNAP, the care manager would have facilitated those applications. Lastly, client advocacy is demonstrated throughout the process by the care manager’s tenacious efforts to procure benefits, services, housing, and other community opportunities to meet Evelyn’s self-identified goals.

Preserving Care Manager Core Competencies in an Evolving Home Care Environment

Halfway through my fourth decade of care management practice, I am confident that “the more things change, the more they remain the same.” In 1976, when the allowable IRS reimbursement rate was .04 cents per mile and the homemaker or home health aide reimbursement rate was $4.25 per hour, care managers throughout the country struggled to devise reliable assessment instruments for collecting and documenting client information. A handful of nonprofits in local communities, family service associations, and visiting nurse organizations offered a limited choice of service options; notably nursing visits, homemakers, home health aides, companions, and home-delivered meals. Care plans were limited in scope and many communities simply had no community service options. Discharge planners and medical social workers had little choice but to arrange for nursing home placement for those unable to return home. While in many respects the responsibilities of the care manager have remained the same—clinical assessment, care plan development, knowledge of services or benefits, advocacy—expectations regarding clinical expertise have skyrocketed.

For decades the speed of discharge from the acute care hospital, same-day surgery, and outpatient interventions has continued to accelerate. The tagline of being discharged early, “quicker and sicker,” has become routine. We describe skilled nursing facilities as “the way hospitals used to be,” and expect home care providers to care for far more compromised individuals in a community setting. The increased expectations for community-based nurses, social workers, physical therapists, and other disciplines speak resoundingly to the need for more skilled care management knowledge and interventions. If the expectation is for the care manager to be a fully functioning member of an interdisciplinary team, care management skills must be on par with the clinical skills and protocols required of other disciplines. This concept is not meant to suggest that the care manager adopts or mimics the same skill set as the community nurse, for example, but that the care manager is able to understand the nurse’s perspective and recommendations, respond appropriately, and contribute in a meaningful way in all aspects of care plan development.

These higher expectations pose a constant threat to the care management profession. Historically, care management practices boasted a staff of master’s-prepared social workers and registered nurses, working internally as a team and prepared to actively participate and in many circumstances to lead broader interdisciplinary teams. This type of practice is no longer demonstrated, particularly in publicly funded care management models.

In Connecticut, for example, regulations and contract deliverables regarding care management education and experience do not require master’s degree preparation in social work and instead allow for a broad range of vague, generic undergraduate program preparation (State of Connecticut, 2019). Despite the availability of sound accreditation bodies, such as the National Academy of Certified Care Managers (NACCM), there is no structural incentive for a care manager to achieve this level of expertise.

‘The term “cultural humility” has come to replace “cultural competence.” ’

A decade of stagnant rate reform in Connecticut complicates the landscape because nonprofit community care management providers are tacitly unable to compete with hospitals, insurance carriers, and even state government in attracting experienced, educated staff. The responsibility for professional staff education falls to the care management provider.

The “Health Assessment for Social Workers” in-service program is offered in some organizations to teach staff the basics regarding systems review, common conditions, interventions in healthcare for older adults, and how to contribute to an interdisciplinary team. And it is important to note that private care management practices and associations, such as the Aging Life Care Association, continue to recognize varying degrees of expertise, academic preparation, and certification through their designations. In the private market, the consumer’s expectations in this regard support this model (Cress, 2007).

Responding to Increasing Cultural Diversity in the Communities a Care Manager Serves

Care managers have always been expected to recognize the impact of cultural diversity on the assessment and care planning process. The increasing demographic diversity of our country demands an even deeper appreciation for this agenda (Cress, 2007). The term “cultural humility” has come to replace “cultural competence.” While it is helpful to learn as much as is reasonably possible regarding cultural and healthcare traditions, care managers cannot expect to become experts in the lived experience of clients and families from all cultural backgrounds. This is an opportunity for the client and family to become the care manager’s best teacher.

Emerging recognition of the need for cultural humility is evident in work with the aging LGBT population. The last decade records unprecedented advances in this area of practice as LGBT advocacy efforts have demanded change. “Getting It Right,” a best practice model at Connecticut Community Care (CCC) funded by the John H. & Ethel G. Noble Charitable Trust, took a microscope to all aspects of the organization’s policies and practices, from governance to human resources to marketing and communications, to ensure open and affirming LGBT practices were in place. Referral and assessment questions were refined to be more inclusive of LGBT consumers and expert staff training was provided. At the initial assessment visit, care managers share an attractive brochure regarding the organization’s commitment to LGBT inclusion.

The effort is garnering the desired effect: An older man living alone in a tiny urban apartment reviewed the brochure with the care manager, went to his hall closet and came back with a box of photographs and told the care manager that he had never before been able to share the pictures of his deceased partner with anyone. At another assessment visit, the daughter who lived with her older mother called her spouse on the spot to tell her that “we can put the photographs back on the refrigerator.” Of equal importance, direct service provider organizations have enrolled in the CCC “Getting It Right” certification program so that their organizations also address this need.

Care Manager Role Increasingly Important to Ensure Person-Centered Care

The challenges and complexities of everyday life in this country have had a formidable impact on clients, their caregivers and, as a result, on care management professionals. Care managers were always expected to flexibly, resiliently adapt to the fluid social environment, but expectations have increased considerably in this regard. Chronic unemployment, lack of affordable housing, drug and alcohol abuse, domestic violence, and food insecurity represent a sample of the realities confronted by clients, families and care managers. System barriers challenge the best advocacy efforts and credible solutions are few. Waiting lists for affordable housing run in the hundreds, and determining eligibility for Medicaid and other benefits can be a maddeningly lengthy and cumbersome process. Most care managers bring little personal or professional experience to this effort, elongating the learning curve.

Perhaps the most profound change in care management practice is the role of technology in all aspects of this work. The thirty-page paper assessment tool has been replaced by a sleek laptop. Documents are shared in real time. Families all over the world participate in Zoom conference calls. As a result of the COVID-19 pandemic, federal and state agencies have waived in-home assessment requirements so that clients can be assessed “virtually.”

A host of technological advances in products and services enhance the quality and efficiency of the consumer’s home care plan. Mobile applications use Amazon Echo and Alexa to center elders in a “care circle” of loved ones, proximate or distant, to coordinate services, create calendar events, and take advantage of “check-in” features. Tracking systems monitor medications, falls, and wandering. Technology enhances exercise motivation including Fitbit and Wi-Fi games. Robotic pets comfort individuals with dementia. One of the many challenges moving forward is the moral and ethical ambiguity of “nanny cams,” sensors, and other tracking devices through which family members “monitor” the behavior of their elders.

During the earlier decades of care management practice, controversy abounded as to whether care management was, in fact, a distinct service entity or merely a costly, unnecessary duplication of other services. Direct service provider organizations such as visiting nurse and family service associations and licensed home healthcare agencies stridently advocated with state legislators and public officials to eliminate the role of the independent care management entity. The irony of today’s landscape is inescapable: Everyone is now a care manager. From health systems to skilled nursing facilities, from the Veterans Administration to private, non-licensed home care providers, from senior housing to adult day centers, care management is now in vogue.

Ironically, most organizations that have developed care management roles have done so not to ensure the independent selection of providers but rather to direct the consumer to services their own organization controls in an effort to maintain or increase market share. The concept of the care manager as expert in matching specific consumer needs to a host of potential provider organizations and supporting the consumer and family in selecting the most appropriate provider has been replaced by care managers employed directly by providers to encourage increased use of the organization’s services exclusively. Private care management providers achieve their revenue goals through the sale of their homemaker/companion/personal care/live-in services, not their care management. The care manager actually “manages a book of business,” and may be rewarded for the number of direct service hours delivered.

Efforts have been made to increase the efficiency of care management through the adoption of “tiered” care management models that recognize that the intensity of care management need differs from client to client and that some care management tasks can be performed by paraprofessional case aides, access coordinators, and others. In the Connecticut Home Care Program, for example, clients are identified as Tier A, Tier B, and Tier C, relative to the consumer’s anticipated need for and frequency of care management intervention (State of Connecticut, 2019). Clients can be efficiently transferred from one tier to another whenever necessary. Telephone calls to arrange medical appointments and related transportation, check on the status of a housing application, or refer a client for fuel assistance can be conducted by an assistant working under the supervision of a care manager.

At its core, care management is a universal language, embracing person-centered values and commitments. Technological advances may continue to enhance the efficiency of the assessment and care planning process and expedite reimbursement. But care management will remain essentially the language of relationships, culture, service, and quality of life—one individual, one family, at a time.

Molly Rees Gavin is past president of Connecticut Community Care in Bristol, Connecticut. She can be contacted at


Capezuti, E., et al., eds. 2007. Evidence-Based Geriatric Nursing Protocols for Best Practice, 3d ed. New York: Springer Publishing.

Cress, C. J. 2007. Handbook of Geriatric Care Management, 2d ed. Sudbury, MA: Jones and Bartlett Publishers.

Geron, S. M., and Chassler, D. 1994. Guidelines for Case Management Practice Across the Long-Term Care Continuum. Bristol, CT: Connecticut Community Care, Inc.

Health Information and Management Systems Society, Inc. 2019. “Social Determinants of Health: Can Zip Codes Influence Health Outcomes?” Retrieved August 21, 2020.

Kathol, R. G., Perez, R., and Cohen, J. 2010. The Integrated Case Management Manual: Assisting Complex Patients Regain Physical and Mental Health, 1st ed. New York: Springer Publishing.

Quinn, J. 1993. Successful Case Management in Long-Term Care. New York: Springer Publishing.

State of Connecticut. 2019. Purchase of Service Contract with Connecticut Community Care, Inc., July.