CCM

Care Management is the core of case management practice and the largest domain on the CCM exam. This section covers the case management process from case finding through closure, case management models and tools, levels of care and care settings, long-term care, transitions of care and care coordination, medication management, management of clients by type of care, care of people living with HIV, population health across the lifespan, palliative and hospice care with chronic pain management, and advance care planning. Expect scenario questions that ask what the case manager should do FIRST or what is MOST appropriate at a given step. On the exam, Care Management makes up about 30% of scored questions (45 of 150).

The Case Management Society of America (CMSA) defines case management as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes.” The definition highlights three recurring exam themes: case management is collaborative, it is client- and family-centered, and it balances quality with cost.

Case managers work across the entire care continuum, helping clients navigate complex health and human service systems and bridging gaps between clients and the services they need. Effective case management improves care quality, enhances client satisfaction, and controls costs through appropriate resource utilization. The case manager does not replace the treating provider; the case manager coordinates, facilitates, and advocates so that the client receives the right care in the right setting at the right time.

The process is cyclical, not linear. Monitoring can reveal new needs that send the case manager back to reassessment and replanning at any point. The Commission and the CMSA Standards of Practice describe the same core phases, summarized below.

➜

➜

➜

➜

case finding, eligibility,

comprehensive needs

client-centered SMART

risk

and strengths

goals

link, authorize,

track outcomes; close or

communicate

transition

Case Finding, Screening, and Caseload Selection

Case finding (client identification) locates individuals who may benefit from case management. Sources include claims and utilization data that flag high utilizers or gaps in care, predictive modeling and health risk assessments, provider referrals of clients with complex needs, hospital admission screening, and self-referral or family referral. Because the goal is early intervention, the best case-finding systems identify clients before a crisis rather than after repeated admissions.

Commonhigh-Riskindicatorsusedinscreening

Category	IndicatorsThatTriggerReferralorFurtherScreening
Utilization	Frequentemergencydepartmentvisits;multiplehospitalizationsorareadmissionwithin30
	days; extended length of stay; high -cost claims; repeated denials or out-of -network use
Clinical	Multiplechronicconditions;catastrophicdiagnoses(majortrauma spinalcordinjury traumatic , ,
	brain injury transplant burns high -risk neonate); new cancer diagnosis; complex medication , , ,
	regimenorpolypharmacy;poorlycontrolledchronicdisease
Functional	NeworworseningdependenceinADLsorIADLs;falls;cognitiveimpairment;needfordurable
	medicalequipmentorhomeservices
Behavioralhealth	Serious mental illness; substance use disorder; co-occurring disorders; suicide risk;
	nonadherencelinkedtodepression
Psychosocialandsocial	Livesaloneorhaslimitedoroverwhelmedcaregivers;homelessnessorhousinginstability;food
	insecurity;lackoftransportation;limitedhealthliteracyorlanguagebarriers;suspectedabuse
	orneglect;financialhardshiporuninsuredstatus
Transitional	Discharge to a new setting; unsafe discharge plan; history of failed transitions; end -of -life
	decision-making needs

Screening determines whether an identified individual meets the program’s criteria for enrollment and how intensive services should be. Criteria typically weigh diagnosis, functional status, utilization patterns, psychosocial factors, available support, and benefit eligibility. Risk stratification then places individuals into tiers by complexity and need. Not every identified client requires intensive case management: some are best served by disease management, wellness programs, or periodic monitoring.

Acuityandseveritytiers(Illustrativestratification)

Tier	TypicalClientProfile	CaseManagementIntensity
Lowrisk	Stable , well -controlled condition; strong support; good self -	Wellness education periodic , ,
	management	outreach
Moderaterisk	Oneortwochronicconditionswithoccasionalexacerbations;	Diseasemanagement;scheduled
	somebarriers	contacts(eg monthly) . .,
Highrisk	Multiplecomorbidities recentadmissions psychosocialbarriers , ,	Activecasemanagement;frequent
		contacts(eg weekly) . .,
Complexor catastrophic	Catastrophicinjuryorillness unstablecondition major , , transitions endoflife ,	Intensive often face-to-face; , asoftenasdaily	contacts 1

Caseload assignment matches clients to case managers. An appropriate caseload size depends on client acuity and complexity, the practice setting, geography and travel time, the case manager’s experience and credentials, available technology and support staff, and non-case-management duties. There is no single correct number: a telephonic case manager with low-acuity clients can carry far more cases than a field case manager handling catastrophic injuries. Assignment should also consider the case manager’s expertise (for example, pediatrics, oncology, or workers’ compensation) and the client’s language and cultural needs.

Screening decides whether a client needs case management and at what intensity; assessment determines what the client needs. If a question asks what comes before care planning, the answer is a comprehensive assessment, not a referral or a service authorization.

Comprehensive Needs Assessment

The comprehensive assessment examines every dimension that affects the client’s health and ability to follow a plan of care. It draws on the client interview, the family and caregivers, the medical record, treating providers, and standardized instruments, and it identifies strengths and preferences as well as problems.

Domain	WhattheCaseManagerEvaluates
Physicalandmedical	Diagnoses history currenttreatments medications providers symptoms nutrition pain andoverall , , , , , , , ,
	healthstatus
Functional	ADLs IADLs mobility fallrisk cognition sensorydeficits andneedforassistanceorequipment , , , , , ,
Behavioraland	Mental health conditions substance use coping mechanisms emotional well -being cognitive , , , ,
psychological	capacity andreadinessforchange ,
Social	Familyandcaregiversupport livingsituation finances insuranceandbenefits employment , , , , ,
	education transportation andcommunityconnections , ,
Environmental	Homesafety accessibility adequacyofhousingandutilities andneighborhoodresources , , ,
Culturalandspiritual	Healthbeliefs language religiouspractices andpreferencesthatshapedecisions , , ,
Health literacy and self -	Understandingoftheconditionandregimen learningneeds andpreferredlearningstyle , ,
management
Strengthsandgoals	Existingcapabilities resources motivation andwhatmattersmosttotheclient , , ,
Advancecareplanning	Existingadvancedirectives surrogate andcarepreferences , ,

Assessment requires strong interviewing skills and clinical knowledge. Rapport encourages openness; active listening shows genuine interest in the client’s perspective; clarifying questions confirm accurate understanding; and cultural sensitivity recognizes how background influences health beliefs and preferences. Standardized assessment tools give structure and ensure comprehensive coverage. Motivational interviewing techniques gauge readiness for change and support behavior modification, and family assessment recognizes caregivers as integral to the success of the plan.

Strengths-based practice builds on the client’s existing capabilities and resources rather than focusing only on deficits. Understanding the client’s preferences is what makes the resulting plan person-centered.

Care Planning

Care planning translates assessment findings into actionable strategies. The case manager and client first identify and prioritize problems (safety and urgent medical needs first), then set measurable goals aligned with the client’s preferences. Short-term goals provide achievable milestones; long-term goals address the ultimate desired outcomes. Goals are written from the client’s perspective and should be SMART.

Smartgoals

A goal such as “improve diabetes control” is not measurable; “the client will check blood glucose twice daily and bring the log to the primary care visit in two weeks” is. Intervention planning then identifies the actions that will achieve each goal: evidence-based interventions, resource identification that matches needs with available services, coordination planning that defines how multiple providers will work together, and contingency planning for complications or setbacks.

The written care plan documents problems, goals, interventions, responsible parties, and timelines. It must be understandable to the client and family and communicated to everyone who has a role. Client participation promotes engagement and adherence; a plan the client did not help create is rarely followed. The plan is reviewed and revised regularly as needs change and goals are met.

Implementation, Coordination, and Advocacy

Implementation puts the care plan into action. The case manager links the client with services, makes referrals to specialty care, social services, and community programs, secures prior authorization for services that require it, and coordinates scheduling of appointments and service delivery. Care coordination keeps service delivery seamless across providers and settings: team communication prevents fragmentation and duplication, care conferences bring stakeholders together for collaborative planning, and information is shared with providers who need it while protecting privacy.

Advocacy addresses barriers the client meets in accessing services. It includes system navigation, helping the client understand and work within complex systems, appeals and grievances that challenge inappropriate denials, and policy advocacy on systemic barriers that affect client populations. Advocacy must balance the client’s interests with ethical obligations and resource constraints, and it should build the client’s capacity to advocate for themselves.

Monitoring, Evaluation, and Closure

Monitoring tracks progress and identifies emerging needs through regular contact by telephone, in-person visits, or secure electronic communication. Contact frequency is driven by acuity: a client in the complex tier may need daily contact, while a stable client needs only periodic check-ins. Each contact, finding, and action is documented. Evaluation measures outcomes and the effectiveness of the plan using clinical indicators, functional status, quality of life, utilization, cost, and client satisfaction. Failure to progress prompts reassessment and plan revision, not simply more of the same services.

Reason	CaseManagerAction
Goalsmetormaximumbenefit	Confirm stability provide self -management resources and transition to a lower intensity of , ,
reached	serviceifneeded
Clientnolongerneedsorqualifies	Lossofeligibility benefitexhaustion orchangeofpayer;linktoalternativeresourcesbefore , ,
forservices	closing
Clientdeclinesfurtherservices	Respect the right to refuse; explain the consequences and how to re-engage; document the
	discussion
Clientislosttocontact	Makeanddocumentreasonableoutreachattemptsfollowingprogrampolicybeforeclosing
Transferordeath	Transfertoanothercasemanager program orsettingwithacompletehandoff;closewitha , ,
	summary

Closure prepares the client for independence. The closing summary documents the episode of care, the goals and outcomes achieved, the reason for closure, and any referrals made. Closure should never be abrupt: ending services without notice or a transition plan can constitute abandonment.

Case Management Models and Tools

Case management is delivered through several models that differ in who the case manager works for, where services occur, and how intensive the relationship is. The exam expects candidates to recognize each model from a short description and to match a client’s needs to the model that fits.

Model	KeyFeatures
Broker(generalist)	Casemanagerassessesneedsandbrokers orlinks clientstoservicesprovidedbyothers;minimal , ,
	directserviceandlimitedongoingcontact Efficientforclientswithmodestneeds . .
Clinical(intensive)	Casemanageralsoprovidesdirectclinicalservices(forexample counselingorclinicaleducation) ,
	alongwithcoordination;lowercaseloadsanddeeperrelationships .
Strengths-based	Focusesonclientstrengths choices andcommunityresourcesratherthandeficits;therelationship , ,
	itselfiscentral Widelyusedinbehavioralhealth . .
Rehabilitation Primarycare/medicalhome	Goal -oriented toward maximizing function and independence and where applicable return to w1ork; , , commoninworkers’compensationanddisabilitymanagement . Case manager embedded in a primary care practice or patient-centered medical home coordinating , acrossspecialistsandcommunityservices .

Casemanagementmodels(Continued)

Model	KeyFeatures
Hospital(acutecare)	Focusesonutilization throughput anddischargeplanning Thetriadmodeldividesworkamongthe , , .
	RNcasemanager thesocialworker andautilizationreviewspecialist;thedyadmodelpairsanRN , ,
	casemanager(clinicalcoordinationandutilization)withasocialworker(psychosocialneeds);some
	hospitalsuseanintegratedmodelinwhichonecasemanagerperformsallfunctions .
Payer-based	Employedbyahealthplan workers’compensationcarrier orotherpayer;managesbenefitsand , ,
	utilization coordinates care for high -risk members and often works telephonically , , .
Telephonic/virtual	Servicesbyphone video portal andremotemonitoring;efficientforlargepopulationsand , , ,
	geographicallydispersedclients .
Community-based / field	Casemanagermeetsclientsinhomes shelters andcommunitysettings;addressessocial , ,
	determinants and hard -to-reach populations .
AssertiveCommunity	Amultidisciplinaryteam(psychiatricprescriber nurses peerspecialists substanceuseand , , ,
Treatment(ACT)	employmentspecialists)deliversservicesdirectlyinthecommunity withsharedcaseloads verylow , ,
	client-to-staff ratios and 24/7 availability for adults with serious mental illness at high risk of ,
	hospitalization .
Independent/private	Hireddirectlybyclients families attorneys oremployers;commoningeriatriccaremanagementand , , ,
	lifecareplanning .

ACT is distinguished from ordinary intensive case management by its team-based shared caseload and by delivering treatment directly instead of referring out. A client with serious mental illness who has repeated psychiatric admissions and cannot engage with clinic-based services is the classic ACT candidate.

Evidence-Based Tools and Pathways

Case managers use standardized tools to make practice consistent, measurable, and defensible. Clinical pathways (critical pathways or care maps) outline the expected sequence and timing of interventions for a diagnosis or procedure, such as a joint replacement or heart failure admission. Deviations from the pathway, called variances, are tracked and analyzed; a variance may originate with the client, the provider or practitioner, the system, or the community.

Tool	Use
Clinicalpracticeguidelines	Evidence-based recommendations for managing a condition; the foundation of disease
	managementprotocols
Clinical/criticalpathways	Day-by-day or phase-by-phase plans with expected outcomes; used to reduce variation	and
	lengthofstay
Utilizationmanagementcriteria	Standardized medical necessity and level -of -care criteria such as InterQual and MCG (formerly
	MillimanCareGuidelines) usedtoevaluateadmissions continuedstays andservices , , ,
Standardizedassessment instruments	Validatedtoolsforfunction cognition depression fallrisk andcaregiverburden(forexa1 mple , , , , , Katz ADL index Lawton IADL scale PHQ-9 Mini -Cog) , , ,

Commoncasemanagementtools(Continued)

Tool	Use
Riskandreadmissiontools	Predictivemodelsandindexes(suchastheLACEindex)thatidentifyclientswhoneedproactive
	intervention
Careplantemplatesandprotocols	Structureddocumentationthatensureseverydomainisaddressedandoutcomesaretracked

Cost Containment

Cost containment in case management means delivering the right care, in the right setting, at the right time, by the right provider, at the right cost, without compromising quality or safety. It is achieved by preventing avoidable utilization, not by denying needed care. The case manager documents cost savings as hard savings (direct, measurable reductions such as a negotiated rate or an avoided day of inpatient care) and soft savings (potential or avoided costs, such as a prevented complication or readmission).