Read the attached article- Essentials of Advocacy in Case Management and then, answer the following questions: Case Managers have four duties a

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Professional Case Management Vol. 21 , No. 4 , 163 – 179

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The advent of the Patient Protection and Afford- able Care Act of 2010 (PPACA), Value-based Purchasing (VBP), the Institute for Healthcare

Improvement’s (IHI’s) Triple Aim, and the National Strategy for Quality Improvement in Health Care has pressured health care stakeholders to focus on qual- ity, safety, and cost of services and resources more than ever before. These priorities may sound simple and similar in focus. The reality, however, is that they are complex and require the collaboration of stake- holders from across the health care continuum, care settings, providers, payers, employers, and, most importantly, consumers. There is no better time than now to focus on advocacy as an essential strategy, embedded in case management programs. Such stra- tegic attention to advocacy enhances the capabilities of health care delivery systems and assists in meet- ing the challenges of the Triple Aim and the priori- ties of the National Quality Strategy while meeting the expectations of the PPACA and VBP programs. There is no doubt that advocacy in case manage-

Address correspondence to Hussein M. Tahan, PhD, RN, MedStar Health, 5565 Sterrett Pl, 3rd Floor, Columbia, MD 21044 ( [email protected] ).

The author reports no confl icts of interest.

A B S T R A C T Purpose/Objectives: This article describes the meaning and underpinnings of advocacy in the fi eld of case management and shares essential principles and concepts for effective client advocacy. Primary Practice Setting(s): All practice settings across the continuum of health and human services and case managers of diverse professional backgrounds. Findings and Conclusion: Advocacy is vital to case management practice and a primary role of the professional case manager. It is rooted in ethical theory and principles. Successful case managers apply advocacy at every step of the case management process and in every action they take. Part I of this 2-part article explores the ethical theories and principles of advocacy, the perception of case management-related professional organizations of advocacy, and types of advocacy. Part II then presents a client advocacy model for case managers to apply in their practice, describes the role of advocacy in client engagement, and identifi es important strategies and a set of essential competencies for effective case management advocacy. Implications for Case Management: Acquiring foundational knowledge, skills, and competencies in what advocacy is equips case managers with the ability and confi dence to enact advocacy-related behaviors in the provision of care to achieve desired outcomes for both the clients and health care agencies/providers alike. Case management leaders may use the knowledge shared in this article to develop advocacy training and competency programs for their case managers.

Key words: advocacy , advocate , case management , case manager , client advocacy , ethics

Essentials of Advocacy in Case Management: Part 1 Ethical Underpinnings of Advocacy—Theories, Principles, and Concepts

Hussein M. Tahan , PhD, RN

DOI: 10.1097/NCM.0000000000000162

ment contributes to improving the client experience of care including quality and satisfaction, improving the health of populations, and reducing the per capita cost of health care ( IHI, 2016 ).

The IHI explains that the Triple Aim presents a framework for health care organizations to use in opti- mizing the performance of their care delivery systems. However, the IHI claims that currently no one care setting demonstrates accountability for all aspects of the Triple Aim ( IHI, 2016 ). Therefore, breaking down traditional barriers and pursuing collaboration across care settings and providers are important to achieve the goals of better care experience, better population health, and lower cost. Case management is poised to

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play an important role in moving health care systems toward addressing the challenges of the Triple Aim. Advocacy is integral to the case management approach and known to improve the client’s experience of care and ensure better service quality and safety as the cli- ent transitions across the complex continuum of care and diverse providers. Case managers today through their involvement in care coordination, transitions of care, interdisciplinary collaboration, and provision of timely access to care for clients and their support sys- tems are found to be advocating for these clients every step of the way and beyond any one particular care setting or provider. Despite the importance of such role, case management experts and leaders are yet to focus on understanding the meaning of advocacy for the case manager and its value in care delivery and the improvement of the client’s experience of care.

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 you as both case managers and leaders, urging you to pause and evaluate the state of advocacy in your programs and perhaps conduct a gap analysis by comparing your current advocacy practices with the knowledge and tactics provided in this article. Part I explores the ethical theories and principles of advocacy, the perception of case management-related professional organizations of advocacy, and types of advocacy. Part II presents a client advocacy model for case managers to apply in their practice, describes the role of advocacy in client engagement, identifi es important strategies for the enhancement of client advocacy, and explains the set of essential competen- cies for case managers for the effective execution of their advocacy role. Finally, this two-part article urges you to develop strategic goals on advocacy for your case management programs and use the knowledge provided herein for that purpose, especially in design- ing case managers’ advocacy-related competencies;

articulating specifi c advocacy actions for each of the phases of the case management process; and identify- ing advocacy-based measures for use in the evalua- tion of the client experience of care and other quality and safety program goals.

The author published a version of this article ini- tially in 2005 (Tahan, 2005). More than a decade later, although advocacy has taken a center-stage position in our case management practices, as evident in the codes of ethics and professional conduct for case managers, standards of case management practice, and client/ support system-centered care, not much has been published about advocacy and innovations in its inte- gration in the roles of case managers. An exception is the concise mention of advocacy in case management- related codes of ethics and standards of practice. This two-part article attempts to fi ll this continued gap in the case management advocacy literature.

ADVOCACY: A MUST FOCUS FOR CASE MANAGEMENT

The concept of advocacy is not new to health care service delivery and practices. It is an important and powerful aspect of case management. It also is spe- cifi cally embedded in the role case managers play in the provision of care to clients and their support sys- tems. It is inherent in every activity they perform, from diagnosis of clients’ problems to recovery or death, that is, across the continuum of care, while providing health and human services, and during every encounter with a client. Advocacy is at the heart of the case manager’s role and the relation- ship with the client and client’s support system. It is a moral and ethical obligation that can be evi- dent in the decisions and actions of case manag- ers when managing, coordinating, and facilitating health care delivery; deciding on the appropriate use of resources; and enhancing quality and safety out- comes for their clients/support systems. Moreover, advocacy is an essential element of interdisciplinary collaboration, communication, and cooperation for the purpose of meeting and respecting clients’ needs, desires, interests, and preferences.

Case managers are constantly challenged to maintain a delicate balance while managing health care activities and resources and facilitating a client’s informed decision making. On the one hand, they must identify, assess, and meet the needs and wishes of the clients (i.e., patients and their families and caregivers). On the other hand, they must acknowl- edge the interests of the provider (e.g., physician, hospital), the employer, and the payer (e.g., insurance company or third-party payer). The key strategy to maintaining the balance is advocacy—a fundamen- tal and vital role for all case managers regardless of practice or care setting and professional background.

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

you as both case managers and leaders, urging you to pause and evaluate the state of advocacy in your programs and perhaps conduct a gap analysis

by comparing your current advocacy practices with the knowledge and

tactics provided in this article.

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Case managers in any practice setting are ideally suited to advocate for clients while dealing with the realities of the cost-conscious, managed care envi- ronment ( Hellwig, Yam, & DiGiulio, 2003 ), which tends to focus on “fi nancial bottom line” decision making. Although multiple factors infl uence the need for advocacy, it is generally true that someone in the health care environment must assume the role of cli- ent advocate, particularly for the client whose self- advocacy capability is impaired. Case managers are, without any doubt, in the ideal position to assume this role because of their ability to determine the appropriate amount, type, quality, option, and tim- ing of advocacy required by different clients.

Advocacy provides a powerful context for the many tasks, roles, functions, and responsibilities of case managers. They can achieve this by continu- ally raising the questions: What are the client’s care goals, wishes, and preferences? What is in the best interest of the client and client’s support system? And is the client/support system capable of self- advocacy? Case managers may use advocacy as a way of showing their clients that they are on their side and they are their top priority. They are able to “work the health care system” both within and outside the care setting (e.g., hospital) walls, and across the continuum of care and various involved providers, to ensure that the clients’ needs and care goals are met, resulting in optimal care experience for all. The need for case managers to act in such role is even more pronounced because of the cur- rent climate of health care delivery that relies on case management as a desired strategy for ensur- ing the delivery of cost-conscious, effi cient, quality, ethical, safe, legal, and culturally relevant health care services. This two-part article summarizes some of the essential descriptions of advocacy noted in select case management-related literature in Part I, discusses a model and several practical strategies case managers may use to execute their role as client advocates, and shares an effective approach to advocacy: “maintaining a delicate bal- ance” in Part II.

DESCRIBING ADVOCACY AND ITS PURPOSE

The term “advocacy,” as it appears in the literature, is described as the “essence” of the client–case manager relationship. Advocacy is predominantly client-focused rather than provider-driven; in fact, it is provider (i.e., case manager)-facilitated. Advocacy simply means actively supporting a cause and trying to get others to support it as well. It also is speaking up, effecting change, drawing attention to an important issue or interest, or directing those who are to make certain decisions toward an appropriate and necessary action.

Generally, advocacy aims to promote or reinforce a change in one’s life or environment, in program or service, and in policy or legislation. In health care delivery, these activities focus on health conditions, health care resources, quality of life, and the needs of clients/patients and the public. Advocacy has been defi ned in several different ways. However, there is no single right defi nition or approach to advocacy. This article respects and affi rms the rich diversity of advocacy experiences and perspectives case manag- ers possess that tend to rely on the context of their work environment, the client populations they serve, and the goals and objectives of the case management programs they belong to.

Advocacy has been discussed and defi ned in great detail in the public and social policy literature. How- ever, in case management, it has not been reviewed or described as comprehensively even today despite its importance. The limited, but varied, defi nitions of advocacy communicated in the case management lit- erature share certain core characteristics. Advocacy is noted to be similar to friendship in that it is best when based on open communication, transparency, connec- tion, honesty, respect, truthfulness, and trust; similar to counseling because it is most effective when apply- ing listening, attending, supporting, empowering, engaging, and responding skills; and similar to teach- ing when it involves patience, guidance, and sharing of information by a more knowledgeable individual.

Advocacy entails the pursuit of infl uencing outcomes—including public policy and resource

Advocacy is at the heart of the case manager’s role and the relationship with the client and client’s support system. It is a moral and ethical obligation that can be evident in the decisions and actions of case managers when managing, coordinating, and facilitating health care delivery; deciding on the appropriate use of resources; and

enhancing quality and safety outcomes for their clients/support systems. Moreover, advocacy is an essential element of interdisciplinary collaboration, communication, and cooperation for the purpose of meeting and respecting clients’ needs, desires,

interests, and preferences.

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allocation decisions within political, economic, and social systems and institutions—that directly affect people’s lives. It consists of a set of organized efforts and actions that effect change in a decision maker’s perception and understanding of a problem, issue, or reality with the purpose of bringing clear improve- ments in one’s life. In case management, advocacy is a professional and proactive case manager’s activity or intervention that requires advanced knowledge, competence, and skills and focuses on achieving what is in the best interest of the client/support sys- tem while maintaining the client’s autonomy and self- determination. Case managers engage in advocacy activities at every step of the case management pro- cess while:

• Assessing clients’ needs and those of their support systems.

• Planning, facilitating, coordinating, managing, and integrating required health care services and support resources.

• Monitoring and evaluating the delivery of services and clients’ responses.

• Transitioning the clients from one level of care/ setting or provider to another.

• Educating clients about and engaging them in their treatment plans, tests, and procedure, health care regimens, building self-care and self-manage- ment skills, and understanding how to navigate the complex health care system.

• Monitoring and addressing patient care delays whether related to tests and procedures or respond- ing to their results in an effort to progress care.

• Communicating with payers (e.g., insurance com- panies such as managed care organizations) regarding the clients’ conditions and treatment and transitional plans.

• Obtaining authorizations for treatments and ser- vices necessary for providing care to clients.

• Facilitating shared and informed decision making concerning care options.

• Being transparent with the client and support sys- tem regarding care progression, quality and safety concerns, and cost of services.

CONTEXTS AND UNDERPINNINGS OF ADVOCACY

It is no surprise that the few defi nitions of advocacy in case management practice available in the litera- ture focus on an ethical and legal foundation for such practice (see Table 1 ). For example, Hawkins, Veeder, and Pearce (1998) describe advocacy as a process that aims to promote client empowerment, inde- pendence, and autonomy. According to them, case managers as advocates have an obligation to create an environment that allows the client and/or client’s support system to act in their own best interest, and if they were unable, the case manager will then take on their cause, act on their behalf, defend the cause, and support the client and support system in meeting their health care goals. Examples of this type of case manager advocacy include activities such as fostering clients’ independence; educating clients about their rights, health care services, resources, and benefi ts; facilitating appropriate and informed decision mak- ing; considerations for clients’ cultural values, factors, and interests while delivering care; and identifying cli- ents in need for advocacy to act on their behalf.

Raiff and Shore (1993) focus on service provision in their description of advocacy; that is, being fair and just in the distribution of services and resources. They defi ne advocacy as a process designed to address defi – ciencies that clients encounter when choosing, access- ing, or using service providers. In this situation, case managers assist their clients in gaining access to all of the benefi ts they are entitled for, thereby securing or enhancing a needed service, resource, or entitle- ment. Examples of this type of advocacy include activities case managers may engage in to fi rst “make

They can achieve this [advocacy] by continually raising the questions: What

are the client’s care goals, wishes, and preferences? What is in the best

interest of the client and client’s support system?

Case managers are constantly challenged to maintain a delicate balance while managing health care activities and resources and facilitating a client’s informed

decision making. On the one hand, they must identify, assess, and meet the needs and wishes of the clients (i.e., patients and their families and caregivers). On the other

hand, they must acknowledge the interests of the provider (e.g., physician, hospital), the employer, and the payer (e.g., insurance company or third-party payer). The key strategy to maintaining the balance is advocacy—a fundamental and vital role for all

case managers regardless of practice or care setting and professional background.

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existing services available to clients; [second], to make existing services meet client’s needs; and [third], to develop services to address unmet client needs” (Raiff & Shore, 1993, p. 55).

Pinch (1996, in Flarey, Smith, & Blancett, 1996), however, focuses on bridging the ethical and legal dimensions in the process of advocacy and the prac- tice of case management. She states that client advo- cacy has two facets. The fi rst entails the provision of information by the case manager so that the client can make informed decisions about treatment options, whereas the second is supporting the decisions the client makes. According to Pinch, case managers as advocates ensure that the clients possess the appro- priate and relevant information regarding their health condition, plan of care, and treatment options before self-determination can occur. From the legal perspec- tive, she asserts that the case manager must provide the clients with the particular level of information nec- essary for the process of making informed decisions. Ethically, however, she states that case managers are obligated by the “code of professional conduct” to take on the additional responsibility of supporting the clients in the informed decision-making process regardless of whether their decisions were desirable. Ultimately, the case managers have a moral obligation to be nonjudgmental. They also have a moral commit- ment to enhance clients’ autonomy and to ensure that the clients receive and understand essential and rel- evant information and that their rights are protected.

Hellwig et al. (2003) agree with Pinch’s per- spective of advocacy as a legal and ethical process. They describe advocacy as a philosophical founda- tion for ethical and legal case management practice, a moral commitment to enhancing client’s autonomy, and a process for protecting the most fundamental human right: freedom of self-determination. Accord- ing to Hellwig et al. (2003), case management activi- ties refl ective of advocacy may include “helping the patient to obtain needed healthcare services, assur- ing quality of care, defending the patient’s rights, and serving as a liaison between the patient and the healthcare system” (p. 54).

Daniels (2009) , Treiger and Fink-Samnick (2016) , and Cesta and Tahan (2016) describe a more contem- porary perspective on advocacy—one that is not only grounded in the principles of ethical practice but also infl uenced by current sociopolitical issues such as the PPACA and VBP programs. Daniels (2009) describes advocacy for the hospital-based case manager as actions that adhere to the ethical and professional code of conduct and the standards of case manage- ment practice. She also explains that for case manag- ers to support the best interest of their clients, they must be proactive advocates and the “voice of the cli- ent” in care management decisions. Daniels (2009) continues to indicate that “every interaction must be approached from the perspective of the patient’s [(i.e., client’s)] clinical and fi nancial best interests, and every case manager work activity must, at its heart, support

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TABLE 1 Primary Areas of Focus for Advocacy in Case Management Practice

Author, Year Primary Focus

Cesta & Tahan, 2016 Ethical obligation : Doing what is in the best interest of the patient and family

Safeguarding client’s autonomy and right to self-determination, choice, independence, and informed decisions

Essential characteristic of shared decision making

Promoting, respecting, and protecting the health, safety, and rights of clients and the quality of the care they receive

Daniels, 2009 Scope of practice in hospital-based case management that refl ects professional code of conduct and standards of care

Primary role of the case manager refl ecting the voice of the patient

Viewed as an unwritten contract between the patient and the case manager

Hawkins et al., 1998 Client’s empowerment, independence, and autonomy

Hellwig et al., 2003 Ethical and legal practice as a philosophical foundation

Moral commitment for client’s autonomy

Protection of client’s freedom of self-determination

Pinch, 1996 Bridging ethical and legal practices

Client’s informed decision making

Protection and support of client’s rights

Raiff & Shore, 1993 Eliminating defi ciencies from the delivery of health care services (securing services/resources)

Being fair and just in the distribution of resources

Treiger & Fink-Samnick, 2016 Moral obligation of professional practice

Professional and ethical conduct

Powerful context for the case manager’s tasks, roles, responsibilities, and functions

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the case manager’s advocacy role” (p. 49). Ultimately, Daniels (2009) recommends that case management practice must move away from task orientation to client-centeredness, which can be achieved by build- ing a client–case manager relationship that shifts the interactions from routine questioning to intimate exploration of care options and client empowerment. In this regard, Daniels (2009) emphasizes that case managers must view client advocacy as an unwritten contract between the case manager and the client.

Treiger and Fink-Samnick (2016) , similar to Daniels (2009), explain advocacy from an ethical per- spective as a moral and professional obligation. They also describe it as an essential case manager’s compe- tency and a powerful context for case managers when executing their roles, responsibilities, and functions that include the building of a respectful and empower- ing client–case manager relationship. One of the most valuable contributions of Treiger and Fink-Samnick (2016) to the knowledge and practice of case man- agement advocacy is their framing of it as a neces- sary competency every case manager and leader must develop, demonstrate, and advance on an ongoing basis. They stress the need for such competency as an obligation rather than luxury; that is, an integral com- ponent of every case manager’s role and case manage- ment program ( Treiger and Fink-Samnick, 2016 ).

Cesta and Tahan (2016) bring another dimension to advocacy, one that is of great importance to clients and their support systems as well as other stakeholders

involved in care: quality and safety. They highlight the ethical aspects of advocacy similar to those described by Hawkins et al. (1998) , Hellwig et al. (2003) , and Pinch (1996) . However, they go further and describe advocacy as essential to shared decision making, respecting the client’s right to choice, protecting the client’s health and safety, and ensuring the delivery of quality and safe care ( Cesta and Tahan, 2016 ). This perspective on advocacy enhances the client’s experi- ence of care, which is integral to VBP programs, the IHI’s Triple Aim, and the National Quality Strategy. It also modernizes our view of advocacy as an impor- tant strategy to respond to the demands of today’s health care environment that places the client and community at the center of care delivery.

FOUR PRIMARY PERSPECTIVES ON ADVOCACY

It is sometimes unclear how much, how often, and to what degree case managers must be involved in clients’ advocacy. A rule of thumb case managers may apply is fi rst “allow clients to advocate for themselves to the extent they can.” Case managers’ approach to advo- cacy is dependent on their perspective or framework (see Table 2 ). It also is affected by other factors such as the client–case manager’s relationship; the context of practice; the case manager’s skills, knowledge, and competencies; the client’s level of functioning, cognition, alertness, interests, and willingness; and the situation at hand.

TABLE 2 Four Basic Perspectives on Advocacy in Case Management Practice

Perspective/Framework Main Characteristics

Paternalistic Traditional

Assumes the client is powerless, passive, and lacks knowledge

Assumes the case manager as the “boss”

Case manager is directive

Empowering Contemporary

Assumes that clients are able to be their own advocate and voice own opinions

Clients are empowered participants in their own care

Case managers are client supporter and educator

Shared Responsibility Contemporary

Objectivity is relative

Assumes a joint decision-making process between the client and the case manager

Respects the contributions made by both the client and the case manager

Case managers have a moral obligation to share their professional opinions with th