The Role of a Case Manager and the Four Basic Functions - Assignment Example

The roles carried out by a case manager involve patient referral, delivery of healthcare, adjustment, and evaluation of results for every patient, and most importantly evaluating the entire health program's effectiveness by making adjustments to the health program.

Four basic functions of a case manager
A case manager typically carries out the following functions:
Coordinate and arrange for special services: Case managers must evaluate cases that require specialist attention and refer them accordingly. This ensures patients with complicated conditions are examined and treated by medical practitioners of a given specialty.
Checking available benefits: A case manager determines available benefits for a patient. This enables a patient to take advantage of such benefits available within the hospital setting.

Negotiating rates: It is the function of a case manager to negotiate rates with clients. Different cases are managed at varied rates and in the application of a win-to-win situation between a client and a hospital, the case manager represents the hospital in negotiating the most appropriate rate (Finkelman, 2001).
Counseling services: A case manager in the process of his duties interacts with clients suffering from serious and terminal conditions and as such gets involved in counseling services(Edlin, 2004).

Ten competencies for a good case manager

The essential competencies of a case manager include:
Interviewing skills: case managers conduct interviews frequently to gather and provide information relevant to carrying out case management processes.
Communication: A case manager should successfully obtain and convey complete and accurate information in a caring and respectful manner.

Teaching skills: Evidently, a case manager plays a pivotal role in assisting clients to build skills that are needed to gain independence and take control of their lives.
Critical thinking: In most cases, a case manager will be needed to determine patients’ needs hence ability to think critically becomes paramount for decision-making.
Collaboration and negotiation: A case manager's primary role involves facilitating the client's recipient of services. To effectively perform this task, a case manager must establish a cooperative relationship with all people.

Advocacy: The task of connecting clients to available resources requires mediation and advocacy skills.
Termination: A case manager needs to have the skills necessary for terminating a case as it is the final step in the case management process.
Self-determination and ability to make choices: According to Edlin (2002), similar to other people, a case manager should possess the ability to make their own choices about life decisions as far as case management models are concerned.

Cultural diversity: Culture is commonly defined as an integrated part of human behavior. As such, a case manager must be knowledgeable about their culture to understand people.
Quality of life: The basic role of a case manager is taking care of people’s lives. Therefore, he should ensure that a client receives care that promotes life.

PART B

Five clinical or service quality studies conducted by an HMO and why they are helpful to the quality improvement process
Clinical studies gathered about a patient should be set in an individualized context. A health practitioner must clearly understand the patient’s background, how such information impacts the problem at hand and the reasons why a patient is seeking help at that given time(Jesus, 2001). In this regard, such contextual details require an inquiry into patients' complaints, past admissions and readmissions within four weeks, past cases of drug usage, family history, past medical history, and personal and family history among others.

Family history: This information reveals inherited disorders. Such information may have a considerable bearing on patient problem presentation and therefore, useful as a starting point when diagnosing a patient’s problem.
Personal and social history: It is worth noting that interactions with the wider society have powerful influences on the well-being and health of individuals(Larson and Muller, 2002/2003). Notably, major health inequalities are closely related to social class.
Education: Enquiry about the age at which a patient left school provides useful information for assessing disorders and ailments leading to social function and intellectual deterioration.

Drug history: Enquiry about past drug usage helps in establishing if a patient may be suffering from the side effects of a given drug(Micheletti & Mannis, 2004). In addition, a clinician is in a better position to prescribe a different drug that is more effective in managing a given ailment.
Prior cases of admissions and re-admissions: This information provides a clinician with details of prior serious ailments that a patient has previously suffered. Further, such information provides a client with the best ways to manage a problem affecting a patient. Read More