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UncategorizedMarch 22, 2022

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Professional Case Management

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

Hussein M. Tahan , PhD, RN

A B S T R A C T Purpose/Objectives: This article describes the meaning and underpinnings of advocacy in the field 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 confidence 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

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-

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

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

The author reports no conf icts of interest.

DOI: 10.1097/NCM.0000000000000162

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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, identif 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;

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.

articulating specifc 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 fll 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-cifcally 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.

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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.

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 “fnancial bottom line” decision making. Although multiple factors inf 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, eff 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 defned in several different ways. However, there is no single right defnition or approach to advocacy. This article respects and affrms 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 def 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, def 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 inf uencing outcomes—including public policy and resource

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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.

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 defnitions 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 benef 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 defne advocacy as a process designed to address def -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 benefts 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 f 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?

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

Author, Year Primary Focus

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 ref ects professional code of conduct and standards of care

Primary role of the case manager refecting 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 defciencies 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

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

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 frst 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 refective 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 infuenced 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 fnancial best interests, and every case manager work activity must, at its heart, support

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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 frst “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

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 the clients

Engaging Contemporary

Thought to infuence individual and population health

Reliance on patient activation: understanding patients’ readiness to change and willingness to participate in self-care and self-management

Counseling and supporting rather than judging and demanding

Clients are in control of their own health while case managers function as a catalyst for change

Paternalistic Traditional

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Hellwig et al. (2003) applied two perspectives when they explained the many defnitions of advo-cacy available in the literature: traditional paternal-istic and contemporary empowering. The traditional paternalistic perspective assumes that the client is powerless, passive, and lacks suff cient knowledge. In contrast, it describes the case managers as the “boss” and to have far wider knowledge about the health care system and more power based on their profes-sional connections than their clients. Because of this, the clients may not always be able, or perhaps will-ing, to determine what is in their own best interest. The clients may not want the information, or they may not be able to understand it, and therefore case managers must be directive and act on their behalf; that is, be the client’s voice and decision maker.

The contemporary empowering view, however, assumes that knowledge is power and that it is the absolute necessary commodity case managers may use to enable clients to make informed decisions, be their own voice, and be empowered participants in their care. According to this perspective, case manag-ers assume that their clients are active participants in their care and in making its related and neces-sary decisions, have choices, and voice their opin-ions regarding their treatment options, interests, and plans of care. Case managers also maintain that the clients are the key architects of their own life, life-style behavior choices, and health care services in the form of the care options they choose and that no one knows what is best for the client other than the client himself/herself. Regardless, however, both perspec-tives stress the importance of the case manager’s role as a client educator, counselor, and supporter.

Taylor (2005, in Cohen & Cesta, 2005) agrees with the two perspectives described by Hellwig et al. (2003); however, she adds a third that seems more practical and realistic. It is the perspective of shared responsibility; that is, advocacy driven by shared decision making between the case manager and the client. This view is based on a moral commitment to the client’s autonomy and self-determination. It primarily respects the roles played by both the case

manager and the client and their contributions to informed decision making that is usually a by-prod-uct of shared knowledge, discussions, and opinions. What is of great importance in this perspective is that the client/support system make decisions that are based on what is right for them and consistent with their values, beliefs, culture, moral identity, and level of comfort.

The shared responsibility perspective describes objectivity as being relative. It rejects the approach of noninterference by the case manager as well as the absolute passive and powerless state of the client. Rather, it emphasizes the nature of intersubjectivity of decision making resulting from the role of the case manager as a client educator, counselor, and sup-porter. This intersubjectivity occurs as the case man-ager and the client develop own meanings and percep-tions of things while addressing the situations at hand requiring acts of advocacy. Case managers interject their own professional opinions as they assist, edu-cate, counsel, and support their clients. Such interjec-tions are based on the case managers’ knowledge and previous experiences, as well as their obligations to ensure their clients make informed decisions. Simi-larly, and at the same time, the clients contribute their own opinions and share their knowledge of their care; such sharing is infuenced by their previous experi-ences as well. As a result, advocacy decisions are made jointly on the basis of the exchange of knowledge and the collective agreements reached by both the case manager and the client. What is important about the shared responsibility and decision-making perspective is that it communicates to the clients they have dif-ferent options and they can choose what makes most sense to them. It also denotes to them that the decision is theirs to make. The case manager is their supporter, educator, facilitator, resource person, and counselor during the process and available to assist them in arriving at a decision.

Another perspective on advocacy that has recently been gaining increasing interest is the engag-ing approach. This takes the empowering and shared responsibility perspectives one step further where the

active participants in their care and in making its related and necessary decisions, have choices, and voice their opinions regarding their treatment options, interests, and plans

of care. Case managers also maintain that the clients are the key architects of their own life…

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client develop own meanings and perceptions of things while addressing the situations at hand requiring acts of advocacy.

case manager partners with the client/support system and acts in an intentional manner to enhance the client’s ability to adhere to care expectations, acquire self-management capabilities, actively adopt healthy lifestyle behaviors, and demonstrate mastery in the management of own health needs. This perspective is grounded in the client activation and engagement theories, which are borrowed from the counseling feld, and is thought to contribute to improvement in individual and population health (one of the IHI’s Triple Aims and National Quality Strategy goals), one client at a time. The engaging perspective is contemporary; it uses client activation to determine readiness for change and willingness to participate in self-care and self-management activities. Case man-agers in this approach are the catalysts for change. They place what is in the best interest of the clients at the center of the case management role and empower their clients to assume the driver seat; that is, deter-mine care goals, where to start the change process, and when, how, and at what pace.

The engaging perspective respects the client’s autonomy, right to self-determination, and choice. It expects the case manager to refrain from judg-ment or acting in a critical manner toward the client/ support system. Through counseling-like interac-tions, case managers assist their clients/support sys-tems to verbalize their fears and misconceptions and tackle the barriers standing in the way of change. This is advocacy at its best where case managers:

• Identify what is in the best interest of their clients; • Support their clients in their journey of discovery

of their strengths and identification of their fears, no matter where they are regarding their health and lifestyle;

• Establish through shared decision making a plan of care that is client-centric and consists of inter-ventions that are reflective of the client’s readiness for change and is based on the activation level; and

• Facilitate a supportive and transparent care envi-ronment where the client’s experience of care (i.e., quality, safety, affordability, access, and percep-tion) is a top priority.

Given these four perspectives on advocacy, case managers must rely on the shared responsibility, con-temporary empowering, or engaging approaches. They also must avoid the paternalistic approach to advocacy because it neglects the client’s autonomy or right to self-determination or, in the least, places it at risk. However, case managers may use the paternal-istic approach in unique situations when clients are unable to advocate for themselves or when the cli-ents resist the case managers’ attempts to encourage the clients to make their own decisions, express their interests, communicate their choices, or gain knowl-edge about their rights and health care services and benefts. To establish a consistent approach to advo-cacy, one may say it is best to use the engaging per-spective because it considers both empowerment and shared responsibility as integral components without which engagement may not occur.

CLASSIFYING ADVOCACY

Experts may classify the acts of advocacy in case management practice into four classes (see Figure 1 ) depending on their scope, extent of reach, complex-ity, and degree of impact on the client, health care system, population, and care outcomes. Case man-agers demonstrate advocacy behaviors to assist an individual client, a whole population of clients in a specifc community, or the public at large. Case man-agers also execute these behaviors with the primary purpose of infuencing the health of both the indi-vidual client and the public in a specifc locale or at a national or international level.

Classifying acts of advocacy into groups based on similarities in scope, reach, complexity, and impact allows case managers to understand these acts and better determine which ones are most appropriate to address a specifc situation. For example, advocat-ing for the implementation of a program for calling clients after an episode of care or health encounter may not necessarily affect the health condition of a particular client unless if the use of the program allows for modif cations to meet the specif c needs of the individual client. Therefore, understanding the levels of advocacy and gaining clarity on the aim of

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FIGURE 1 Types of advocacy and their scope.

an advocacy action and the depth and breadth of its reach in advance of execution are essential for the case manager’s success. Case managers may apply four determining factors or criteria in their approach to classify advocacy:

1. Reach: This criterion pertains to who the advo-cacy act affects: is it an individual client, a population of specific illness or in a particular locale, or a system at large (e.g., health care delivery system in the United States), which means the act affects virtually every person at a country level. An example of reach is a advo-cating for a change in a health care law result-ing in all individuals in the country experienc-ing the result of the change (system level). Another example is advocating for the signifi-cant other of a client hospitalized and in critical condition to stay with the client overnight at the hospital (individual level).

2. Scope: This criterion addresses the depth and breadth of the advocacy act; is it internal to an organization and affects the clients served by this organization or external and affects the population at large. For example, advocating for extending clinic hours into the evening allows more clients to access primary care ser-vices (organization and internal level). Another example is advocating for an outreach and health screening program that may affect the population in the service area (community level).

3. Complexity: This criterion reflects the degree of sophistication or difficulty in executing the

advocacy act: is it simple and pertains to an individual client and/or a small group of clients within an organization, or complex and affects the whole population served by the health care industry. This criterion also describes the type and amount of resources (i.e., time, people, money, and equipment/technology) needed to implement the advocacy act. For example, advocating for remote monitoring and digital technology to enhance client engagement may assist an individual client or a client population (may extend up to community level). Another example is advocating for the use of navigators to assist clients in way finding around a care setting (e.g., hospital; individual client up to organization level).

4. Impact: This criterion reflects the level of the contribution of the advocacy act and the extent of the outcomes it may potentially achieve: is it at the micro or macro level. An example is advocating for having specialty radiology diag-nostic tests (e.g., magnetic resonance imaging) during extended weekend hours (individual up to organization level). Another example is advocating for a change in a state or federal health insurance law (community level if state and global level if federal).

On the basis of the aforementioned criteria, there are four types of advocacy: client, organization, community, and global. These are also depicted in Figure 1 taking into account how each of these types of advocacy refects the four criteria. Client advocacy and organizational advocacy are considered more of

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internal and micro level, whereas community advo-cacy and global advocacy are more of external and macro level. Table 3 shares illustrative examples on each of the types.

Client advocacy, also known as individual advo-cacy, occurs at the level of a single client. Client advo-cacy behaviors are considered simple in scope and micro in nature because they impact one person at a time. They are often embedded in everyday case man-agement practice, integral to the client–case manager relationship, and vary on the basis of the needs and interests of the individual client. In addition, they

occur as the case manager assesses the needs of the client and implements the plan of care. Moreover, traditionally. they have been confned to the bound-aries of an episode of illness/care. Today, however, these advocacy behaviors extend beyond an episode of care or care setting to supporting a client across the life span, especially when the client suffers from a chronic illness.

Organizational advocacy, also known as service advocacy, occurs at the level of a health care orga-nization (e.g., hospital) or a program (e.g., diabetes center and chest pain center) within the organization.

TABLE 3 Sample of Case Management Advocacy Activities

Type of Advocacy Sample Activities

Speaking on behalf of the client and about what is in the client’s best interest

Education regarding health care services, insurance benefts, and medical regimen

Seeking client involvement in care planning and decision making

Case conferencing to resolve disagreement

Keeping patient/family abreast of the plan of care

Making referrals to necessary services

Addressing unmet client needs

Securing community resources and support services as needed

Appealing denials of services

Counseling: behavioral modif cation/lifestyle changes

Enhancing self-management skills and abilities

Following-up on clients after an encounter of care

Completion of client activation assessment and executing a plan for client’s engagement

Promoting a desirable patient experience with care

Organization (service) Performance improvement activities

Client (individual) Respect for and protection of client’s autonomy, independence, self-determination, and right to choice

Development of new service/program

Ensuring eff cient, effcacious, and affordable care

Enhancing access to health care services and community support resources including charity care

Provision of care that is evidence-based

Conduct of research that examines outcomes of services provided

Program for follow-up care and posttransition communication targeting client’s safety and continuity of care

Implementing support groups for clients and/or their support systems

Client-centered medical and health home programs

Community (population) Outreach programs

Free screening for disease risk such as diabetes, hypertension, high cholesterol, or lipids

Participation in local public advocacy groups

Ensuring the availability of effective community resources

Securing funds for the provision of services to the underserved

Population health improvement programs

Safeguarding the public’s interest and promoting healthy living

Global (state, national) Lobbying for health care-related law change or proclient regulation

Public policy and political activism

Participation in national public advocacy groups

Legislative class action appeals

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It involves actions that improve the eff cacy and effciency of services and systems of care delivery. Organizational advocacy is of moderate complexity compared with individual advocacy. Although it is implemented in response to recognized def ciencies in a program or organization, it is deemed proactive in nature because it improves or expands the care to be provided to a specifc client population at a future time.

Community advocacy, also known as population advocacy, occurs at the level of the community at large served by an individual health care organization. It is of moderate to high complexity and of moderate system reach. It also involves proactive actions that improve the health of the community such as devel-oping new services needed by the clients that other-wise would have remained nonexistent. Community advocacy actions tend to be macro in scope and more challenging to implement. They are costly and must comply with the health care laws and regulations of the specif c state or county.

Global advocacy, also known as state or national advocacy, occurs at the broader scope that inf uences the health of the public at large. It is of high com-plexity and involves both proactive (e.g., lobbying for proclient regulations) and reactive (e.g., legislative class action appeals) actions that improve the health of the public regardless of geographical boundaries. Similar to community advocacy, global advocacy is macro in scope and impacts the conditions of sys-tems of large scales. It is primarily political in nature and focuses on effecting change in health care policy, laws, and regulations.

Regardless of the advocacy type, case managers as advocates are able to impact the health conditions of clients at various levels. For example, working with an individual client suffering from uncontrolled diabetes and internally within an organization or care setting, the case manager is able to improve this client’s health condition. Through an engaging approach to lifestyle behavior change and respect of this client’s right to choice and self-determination, the case manager is able to achieve desired outcomes (i.e., better health, reduction of avoidable or unnecessary access to emer-gency services, and therefore reduction in cost). When this case manager continues to care and advocate for clients with similar conditions and applying same tac-tics, this case manager is able to move from advocat-ing at the individual and micro level to contributing to the health of a client population (i.e., clients with diabetes) and therefore engaging in advocacy at the community, system, and external levels.

This example demonstrates that the various types of advocacy are interrelated and do exist on a con-tinuum that refects the degree of reach and impact. The wider the reach and the greater the impact are,

the more complex the advocacy act is and the larger its contribution to realizing the Triple Aim and the priorities of the National Quality Strategy is. Case managers must understand that their involvement in day-to-day case management advocacy and at the individual client level allows them to effect change at the population and system levels as well; they are able to contribute to such broader benef t through their caring for one individual client at a time. On the con-trary, case managers involved in social justice, public policy, and lobbying activities for a specif c cause are able to contribute to change at the system level and external to (or beyond) the organization where they are employed and their practice setting. Ultimately, all types of advocacy activities are necessary for successful health system improvement and meeting the IHI’s Triple Aim.

ETHICAL FOUNDATION OF ADVOCACY

The case management practice of advocacy is rooted in ethical theories and principles similar to advocacy in nursing, social work, medicine, and other health disciplines. It is a complex concept and requires case managers to be knowledgeable in ethical principles to be effective client advocates and demonstrate objec-tivity while truly advocating for their clients/support systems. Case managers may be ineffective advocates when they lack skills in demonstrating respect for cli-ents’ right to self-determination, for example. Prac-ticing advocacy with a solid ethical base assists case managers to minimize or completely prevent ethical dilemmas, especially those that may arise between themselves and their clients or between the clients and other providers or the health care system. The ethical foundation of the practice of advocacy also enhances the case managers’ adherence to the code of professional conduct of their professional discipline (e.g., nursing, social work) and that of case manage-ment. General ethical principles, such as autonomy, benef cence, nonmalef cence, fdelity, justice, and veracity, provide case managers with a solid founda-tion for effective client advocacy.

Case managers stand alongside their clients/sup-port systems throughout an episode of care and/or beyond. Such position is best exemplifed in the pro-fessional client–case manager relationship. What is fundamental to this relationship, which contextual-izes the case manager as the client advocate, is the case manager’s ability to act with objectivity and freedom from any external or adverse pressures and interests. Whenever case managers resign to these conficting demands and neglect the obligation of objectivity, they essentially destroy or weaken their professional standing, independence, and f duciary relationship with their clients and clients’ support

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systems. Comparatively speaking, when case manag-ers demonstrate an objective attitude and comfortable command of the general ethical principles, they become effective in bringing about benef cial out-comes for their clients/support systems, advancing the clients’ well-being, and protecting their autonomy and rights to informed choice and self-determination. Case managers also ensure that all clients have equal access to health care services, at the time they need them. Here, there is an implicit requirement for case managers to engage in advocacy, as it is necessary to promote the well-being of clients and do what is in their best interest. This means that case managers as client advocates must always execute their actions while carefully considering the ethical underpinnings of client advocacy and professional practice.

Case managers are responsive to the changing needs of their clients/support systems, dynamics of health care delivery, and demands of the complex processes of interprofessional care provision. Often they are found to resolve conficts, prevent delays in care, negotiate the availability of community-based support services, or manage ethical dilemmas such as end-of-life care concerns. Applying ethical principles and standards to these situations allows case man-agers to remain focused on the clients’ care goals, achieve positive health care outcomes that maximize clients’ quality of life, ensure safety, and respect cli-ents’ autonomy, wishes, and interests. The question then is “how do case managers determine what ethi-cal principles apply to their practice of advocacy?” Treiger and Fink-Samnick (2016) note that a “range of case management standards now exists across professional associations and credentialing bodies” (p. 171), which offer guidance in answering this ques-tion. In fact, these highlight advocacy as an essential ethical principle case managers are ought to adhere to while caring for their clients and support systems and when working toward achieving desirable outcomes for their clients/support systems.

Case managers are bound by professional codes of ethics and standards that guide their practice (see Table 4 ). The Commission for Case Manager Certifcation (CCMC) describes in its Code of Pro-fessional Conduct that applies to board-certif ed case managers from diverse professional backgrounds a number of ethical principles that are important for advocacy. These include placing the public interest above that of the case manager, respecting the rights and inherent dignity of clients, maintaining objectivity in the relationships with clients, and acting with integ-rity and commitment to quality outcomes for clients, appropriate use of resources, and the empowerment of clients in a manner that is supportive and objective. In addition, the CCMC explains that case management practice is guided by the ethical principles of auton-

omy, benef cence, nonmalefcence, justice, and f delity. It also describes advocacy as a means for improving client health, wellness, and autonomy through advo-cacy, communication, education, identifcation of ser-vice resources, and service facilitation ( CCMC, 2015 ).

The Case Management Society of America (CMSA) expects case managers to advocate for their clients at the service delivery, benefts administration, and policy-making levels ( CMSA, 2010 ). The CMSA emphasizes in its standards the obligation of promoting advocacy at both the individual and community or system lev-els. At the individual level, case managers promote cli-ents’ self-determination, informed and shared decision making, and autonomy; recognize and respect clients’ needs, care goals, and strengths; facilitate access to nec-essary services; eliminate disparities; and empower the clients to engage in self-advocacy. On the community or national level, the CMSA encourages case managers to expand the availability of health care services to cli-ents and engage in public policy ( CMSA, 2010 ).

The American Case Management Association (ACMA) focuses on case management mainly in the hospital-based setting; therefore, its standards of case management advocacy address expectations from health care professionals involved in case manage-ment delivery systems including transitions of care. The ACMA describes advocacy as supporting or rec-ommending the access to and creation of new ser-vices on behalf of clients/support systems with the ultimate goal of protecting clients’ health, safety, and rights. Examples of case managers’ role in advocacy according to the ACMA may include identifying the clients’ legal decision maker, promoting clients’ self-determination, respect for clients’ choices and informed decisions, provision of culturally compe-tent care, addressing suspected neglect and abuse of clients, facilitating full access to services and insur-ance benefts, and managing ethical dilemmas or conf icts ( ACMA, 2013 ). On the basis of these exam-ples, the ACMA seems to focus primarily on client (individual)-level advocacy.

The National Association of Social Workers (NASW) is another professional organization that defnes ethical standards for case management, how-ever, only for the social work case manager. It expects the social work case manager to advocate for the rights, decisions, strengths, and needs of clients and to promote clients’ access to resources, community supports, and services ( NASW, 2013 ). The NASW describes the advocacy role of the social work case manager at both the individual and community or national levels. At the individual level, the case man-ager demonstrates advocacy by ensuring that health care organizations and service delivery systems involve clients/support systems in decision making, enhancing clients’ access to services based on their

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TABLE 4 Ethical Perspectives of Professional Organizations on Advocacy

Professional Organization Perspective on Advocacy Examples of How Case Managers Demonstrate Advocacy

American Nurses Association (ANA)

American Case Management Association (ACMA)

Case Management Society of America (CMSA)

Commission for Case Manager Certif cation (CCMC)

National Association of Social Workers (NASW)

“The nurse promotes, advocates for, and protects the rights, health, and safety of the patient” ( ANA, 2015) and … “must articulate nursing value, maintain integrity of the profession, and integrate principles of social justice into nursing and health policy ( ANA, 2015).

“An act of supporting or recommending on behalf of patients/family/caregiv-ers and the hospital for service access or creation, and for the protection of the patient’s health, safety and rights” ( ACMA, 2013, p. 11).

“The case manager should advocate for the client at the service-delivery, benefts-administration, and policy-making levels” ( CMSA, 2010, p. 20).

“Case management is a means for improving client health, wellness and autonomy through advocacy, communication, education, identif ca-tion of service resources, and service facilitation” ( CCMC, 2015, p. 4).

“The social work case manager shall advocate for the rights, decisions, strengths, and needs of clients and shall promote clients’ access to resources, supports, and services” ( NASW, 2013, p. 5).

The ANA’s code of ethics for nurses applies to nurse case manag-ers who are expected to demonstrate advocacy by protecting the clients’ rights to privacy and conf dentiality, enhancing informed decision making, promoting a culture of client safety and protection, rectifying social injustice and health disparities, and changing health policy at various levels.

The case manager demonstrates advocacy by identifying the cli-ent’s legal decision maker, sharing of information on benef ts, risk, cost, and treatment options, provision of culturally com-petent care, promotion of client’s self-determination, balancing resources, resolving ethical conf icts, identifcation of abuse and neglect, and respect for client’s wishes.

Case manager demonstrates advocacy through promotion of cli-ent’s self-determination, informed and shared decision making, education, facilitating access to necessary services, elimina-tion of disparities in quality care and outcomes, expansion of services, and upholding client’s advocacy above all.

Case managers recognize the dignity, worth, and rights of all people, understand and commit to quality outcomes for clients, appropriate use of resources, and the empowerment of clients in a manner that is supportive and objective.

Case managers educate clients about their rights, benef ts, and health care and human services, facilitating informed decision making, and considerations for the client’s values, beliefs, interests, and culture.

The case manager demonstrates advocacy by ensuring that health care organizations and service delivery systems recognize the strengths and needs of clients, involve them in decision making, make services accessible to them based on needs and in a timely manner, and prepare them for transition to other providers or discontinuation of services.

The case manager also advocates at the community or national level by seeking the input of clients on programs, addressing service gaps and barriers, securing funding for services, educat-ing the public regarding health care needs and resources, engaging in social and political action, designing policy that enhance the care of underserved populations.

needs, and preparing clients for transition to other providers or discontinuation of services and ensuring such transitions do not create sudden interruptions and are not perceived as surprises by clients and/or their support systems. At the community or national levels, case managers advocates by seeking clients’ input on programs, addressing service gaps and barriers, educating the public regarding health care needs and resources, engaging in social and political actions, and designing policy that enhances the care of underserved populations ( NASW, 2013 ).

The American Nurses Association (ANA) focuses in its code of ethics on the nursing profession, which also means that nurse case managers must adhere to the code in their practice. Concerning advocacy, the ANA indicates that nurses promote, advocate for, and protect the rights, health, and safety of the clients. It describes nurses, including nurse case managers, as

having an obligation to protect clients from harm, safeguard the clients’ rights of privacy and conf den-tiality, and act on questionable practice that places clients at risk for suboptimal care and harm ( ANA, 2015 ). These activities support advocacy at the indi-vidual client level. The ANA also communicates in its code of ethics for nurses the need to articulate nurs-ing values, maintain integrity of the profession, and integrate principles of social justice into nursing and health policy. This refects advocacy at the national level. In this regard, the ANA addresses nursing’s responsibility toward rectifying social injustices and health disparities and advocating for changes in health policies at a global level ( ANA, 2015 ).

On the basis of the codes and standards of ethics case management-related professional organizations promulgate and the ultimate purpose(s) of advocacy they describe, experts can decipher that the ethical

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practice of case management advocacy consists of the following seven areas of focus:

1. Protecting client’s autonomy, right to choice, and self-determination;

2. Keeping the client as the central focus (i.e., provision of client-centered and culturally competent care) and promoting what is in the client’s best interest;

3. Ensuring client’s engagement in informed and shared decision making;

4. Enhancing client’s access to equitable, timely, and appropriate health care services and resources;

5. Safeguarding client’s right to privacy and con-fidentiality;

6. Improving client’s health outcomes, safety, and quality of life; and

7. Engaging in social justice, and health and pub-lic policy change efforts.

These areas of focus promote advocacy at the client or individual level except for one, “engag-ing in social justice, and health and public policy change,” which mainly addresses advocacy at the

community or global level. It is natural that most of the activities are at the individual level because the large majority of case managers execute their services in the context of “one client at a time.” Despite the focus being mainly at the client level, these activi-ties contribute to improvement in performance at the system level as well because of the cumulative experience of populations of clients. To effectively implement these seven requirements, case manag-ers must demonstrate adherence to 12 key ethical principles (see Table 5 ). These principles govern the practice of case management advocacy and ref ect the way the codes and standards of ethics-related professional organizations have chosen to promote advocacy. Neglecting any of these principles in one’s practice may compromise the expectations of the advocacy role and potentially risk achieving tar-geted outcomes for clients. These principles describe what to expect from case managers who claim to be engaged in client advocacy. Case managers may refer to them as behaviors demonstrative of advocacy and grounded in ethical theories. Although it is neces-sary for case managers to demonstrate all 12 prin-ciples in their practice, some are more evident in the

TABLE 5 Key Ethical Principles of Case Management Advocacy

Principle Highlights/Focus

Demonstrated in behaviors of case managers

Objectivity Maintaining an approach or position that is based on facts and truth, focused on the other (i.e., the client), and void of personal interpretations, feelings, attitudes, positions, biases, and/or perspectives.

Goal orientation Acting in a way that is focused, intentional, and purposeful around realizing articulated aims and end results rather than the tasks themselves while motivates achievement.

Confdentiality Protecting or safeguarding information a client has disclosed in a relationship of trust and with the expectation that it will not be divulged to others without prior permission from the client.

Altruism Acting in a selfess manner; sacrifcing one’s own interests for the sake of the greater good and welfare of others.

Accountability Obligation to accept responsibility and authority for certain tasks or interventions.

Obligation A sense of commitment or duty toward someone or about something. It is demonstrated in behaviors such as respecting, accepting, and adhering to the client’s wishes, preferences, and desires about a particular action of situation.

Full Disclosure Telling the truth about something and sharing all available information with no limitations to ultimately facilitate the client’s ability to make informed decisions.

Influence behaviors of clients

Informed decision Taking a stand about something or a situation after learning all the available facts and information about concern-ing it.

Shared decision making A collaborative process that allows the client and the provider (i.e., case manager) to come to a stand about some-thing or a situation while considering the best available and relevant information and in consideration with the client’s values and belief system.

Empowerment Facilitating one’s ability to recognize own unique individual characteristics including the development of conf dence and strength to think, take action, and decide independently; set realistic goals and fulfl them; and take control of own circumstance.

Engagement Enhancing clients comfort in functioning as partners and active participants in their care including decision making regarding care options. Such partnership should facilitate their self-management skills and abilities demonstrated by the actions they must take to obtain the greatest beneft from the health care services available to them.

Autonomy Self-governance; exercising independence and freedom in taking actions, and demonstrating self-determination.

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clients’ behaviors than in the case managers’ because of their powerful impact on clients/support systems. The principles of objectivity, goal orientation, con-f dentiality, altruism, accountability, obligation, and full disclosure are prerequisite behaviors and their absence in the case manager’s approach to care pro-vision results in lack of advocacy, which ultimately impacts negatively on the clients and their support systems. On the contrary, when clients/support sys-tems exhibit behaviors demonstrative of the prin-ciples of informed decision making, shared decision making, empowerment, engagement, and autonomy, they imply that case managers have adhered to advo-cacy ethical principles, succeeded in their client advo-cacy role, and therefore ethical practice.

As a result of the recent increasing interest in case management advocacy, few community-based organi-zations have been founded with the exclusive mission of client advocacy. One example is the Patient Advo-cate Foundation (PAF), which uses a case manage-ment team to support clients and providers of care by eliminating obstacles clients and/or clients’ support systems (patients) may face when they need to access health care services. This advocacy act may entail the provision of free case management services to those who are facing fnancial or health care access issues as a result of a chronic, life-threatening, or debilitat-ing disease. The PAF also aims to enhance the quality of the health care services, safeguard clients through effective mediation and ensuring the availability of services upon demand, support clients in maintain-ing employment despite their chronic illnesses, and preservation of clients’ fnancial stability relative to their health conditions and diagnoses ( PAF, 2016 ). Although these organizations do not def ne and com-municate professional standards for the ethical prac-tice of case managers, they advance case management advocacy and highlight it as an integral element of case management practice. It is important for case managers to be aware of these and other similar orga-nizations so that they bring them to the attention of the clients who may beneft from what they have to offer, especially when these clients are in dire need for community support resources.

ADVOCACY: A THREE-PRONGED ROLE FOR THE CASE MANAGER

Although advocacy is an underlying theme in virtu-ally all the interventions undertaken by case man-agers, one may examine advocacy as a sole role. In fact, one could argue that all aspects of the role of the case manager are subsidiary to that of the “advo-cate.” This role is complex, challenging, and requires patience, tenacity, skill, and persistence. Advocacy is most necessary in situations of conf ict, disagree-

ments, uncertainty, or vulnerability. For example, advocacy is needed when certain services required by a client are unavailable or are being denied by a third-party payer such as a managed care organization. In this case, advocacy emerges as a balancing act among three interconnected, yet often opposing, parties: the client (patient and family), the health care agency or other clinicians (providers of care), and the insur-ance company (payer). Case management advocacy is also necessary when clients are vulnerable and ben-eft from the support of case managers such as in the case of clients who are deemed either incompetent or unconscious and unable to advocate for themselves or voice their opinions.

Case managers are challenged to balance their relationships with the clients/support systems, health care agencies/providers, and insurers. They must balance this relationship while keeping the primary focus on the client. In fact, they advocate f rst for the client; this is their top priority. Next, they advocate for the agency where they are employed and their fel-low providers; and, third, for the insurance company as warranted. With these intertwined responsibilities and the need to fnd satisfactory solutions to complex issues, case managers’ attempts of advocacy are in the form of a continual balancing act. However, the pri-ority is always clear: “The needs of the clients” or the “clients come f rst.”

For the Client and Client’s Support System

Advocating for the client and client’s support system (family and friends) is a top priority for case manag-ers. It takes place all the time and in every situation or aspect of care provision. It is enacted on the basis of what is best for and needed by the client. Case man-agers tend to work the health care system both within and outside the agency that employs them to ensure clients’ needs are met. Advocating for the client also is evident in the quality of care and the plan of care or type of treatments/services that are provided. Advo-cacy for the client includes facilitating timely access to services, recommending necessary tests and pro-cedures, expediting care progression, enhancing the quality of care and client’s well-being, preventing or managing delays in care provision, and ensuring safety especially during care transitions. In addition, case managers encourage and support their clients in making informed decisions about their care options. Once the needs of clients are determined, case man-agers then provide them with the necessary knowl-edge and resources so that they are better able to act as their own advocates. Thus, advocacy on behalf of the client results in empowerment and engagement and supports the client’s right to autonomy and self-determination at all times.

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For the Health Care Agency or Provider

Advocating for the health care agency (e.g., hospi-tal, skilled nursing facility, care professionals) means working with the agency’s administrators/executives and care providers including physicians, nurses, social workers, and others toward the delivery of appropriate, safe, effcient, and effective care and a timely client disposition to the next level of care. It entails preventing risk management issues and nego-tiating with the insurance company (payer) to autho-rize the plan of care and the utilization of necessary resources, thus ensuring reimbursement. The goal of advocacy on behalf of the provider, including the hospital, is to enhance reimbursement and meet the agency’s goals and targets while ensuring that clients receive safe, quality resources and services that are free of any risk for malpractice litigation.

For the Insurance Company or Payer

Advocating for the payer may be the least common and palatable form of advocacy for a case manager who is practicing in a provider setting. It typically puts the case manager in the “messenger” role, communicating the insurer’s decisions to the health care agency and to the client. Acting as a conduit of information between the insurance company and the other two parties adds another dimension of complexity to the case manager’s advocacy role. This also increases the possibility of role confict or confusion, particularly if the client perceives that the case manager is taking the insurance company’s side. If this occurs, the case man-ager’s relationship with the client is jeopardized, which, in turn, undermines the case manager’s ability to meet set goals. On the contrary, if the case manager practices in the payer-based setting, the client’s interests continue to be the case manager’s top priority despite the need to also apply the payer’s administrative procedures.

To avoid role confict and confusion, case manag-ers must execute their advocacy behaviors based on the principle of “client-centeredness,” that is, putting clients’ interests frst. To comply with this principle, the case manager must pay close attention to the relation-ship between “doing the right thing” and communi-cating the insurance company’s decision to the client. The case manager can accomplish this by maintaining knowledge of the client’s wishes and interests espe-cially as they relate to the client’s medical condition; examine whether these interests are appropriate and realistic; and incorporate them in the discussion the case manager has with the client regarding the insur-ance company’s reimbursement or authorization deci-sions. It is also advisable for the case manager to have an alternate plan of care if the client’s interests and the insurance company’s decisions are in conf ict before the case manager communicates with the client.

CONCLUSION

Advocacy is integral to case management and is applied at every step of the health care delivery pro-cess. Although the strategies employed and the tasks undertaken may differ, the focus on the client is a unifying factor for advocacy. To be effective advo-cates, case managers must maintain such focus in all of their various roles and responsibilities. They also must possess appropriate role-related skills and knowledge that allow them to successfully serve their clients/support systems. Acquiring the necessary knowledge and skills in client advocacy and employ-ing strategies that facilitate advocacy while executing their roles as described in this article will assist them in becoming the desirable advocates for the clients they serve. Ultimately, they are able to impact perfor-mance of health care organizations and systems on the IHI’s Triple Aim: better individual health and care experience, better population health, and affordable care. More specifcally and at the individual client level, case management advocacy ensures that clients access the services they need at the time they need them and in a context of their choosing. Part II of this article focuses specifcally on the required competen-cies of case managers in advocacy, describes a client advocacy model for use by case managers, and shares important strategies that help facilitate the case man-ager’s advocacy role.

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Hussein M. Tahan, PhD, RN, is System Vice President of Nurs-ing Professional Development and Workforce Planning at MedStar Health, Columbia, MD. Hussein has more than 25 years of experience in health care and is an expert in case management. He is a member of the editorial board of Professional Case Management . Hussein is widely published, including being a coauthor of the textbooks Case Management: A Practical Guide for Education and Practice , 3rd Edition, and CMSA’s Core Curriculum for Case Manage-ment, 3rd Edition. Hussein is the knowledge editor for CCMC’s Case Management Body of Knowledge online portal.

For more than 57 additional continuing education articles related to Case Management topics, go to NursingCenter.com/CE.

Instructions: the Commission for Case Manager Certification (CCMC) for This activity is also provider approved by the California � Read the article. The test for this CE activity can only be 2.5 clock hours. This CE is approved for meeting the re- Board of Registered Nursing, Provider Number CEP

taken online at www.nursingcenter.com/ce/PCM. Tests quirements for certification renewal. 11749. LWW is also an approved provider by the District

can no longer be mailed or faxed. of Columbia, Georgia, and Florida CE Broker #50-1223. Registration Deadline: June 30, 2017

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Williams & Wilkins online CE activities for you. This continuing education (CE) activity is provided by Wilkins Department of Continuing Education refers only to its

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1-800-787-8985. Continuing Education Information for Nurses: The authors and planners have disclosed that they have Lippincott Williams & Wilkins, publisher of Professional no financial relationship related to this article.

Case Management journal, will award 3.5 contact hours for Continuing Education Information for Certified Case this continuing nursing education activity. Payment and Discounts: Managers: LWW is accredited as a provider of continuing nurs- � The registration fee for this test is $29.95 This Continuing Education (CE) activity is provided by ing education by the American Nurses Credentialing Lippincott Williams & Wilkins and has been preapproved by Center’s Commission on Accreditation. DOI: 10.1097/NCM.0000000000000174

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