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The Fundamentals of Care Management After National Nurses Week 2021

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We recently celebrated Nurses Week, a special week dedicated to showing gratitude for the nurses who put themselves at risk and work long hours for the health of others, especially during the pandemic.

For readers who did not join us earlier this month, Clinical Engagement Manager Shelley Davis, MSN, RNC, CCM, hosted the webinar, “Care Management 101 – The Fundamentals.” The purpose of the presentation was to delve into the foundational components of care management and provide some basic principles, real-world examples that put theory into action, and common pitfalls organizations can experience when implementing care management programs.

Shelley did this expertly, all while paying homage to the original care manager, Florence Nightingale, whose May 12th birthday marks the end of this commemorative week every year. I thought I would share the most important takeaways from this presentation today on the blog.

Care Management Promotes Long Lives

In the simplest terms, care management is a team-based, patient-centered approach to promoting health and wellness across communities. Through education, advocacy, identification of resources, facilitation of services, and communication, care management sets people on track to improve their health, knowledge, and self-maintenance. With these tools, patients can reduce acute events, like an ER visit or hospital admission, and live longer lives.

Human Interaction is Irreplaceable

If 2020 has taught us anything, it is that nothing in this world can replace human touch and human contact. While telehealth and other forms of technology have created excellent avenues to administer virtual care, the interpersonal relationship between patients and caregivers helps patients feel genuinely cared about and inspires personal change like nothing else.

Care Management is Synonymous with Selfless Service

Shelley broke down the pillars of care management, which highlight how the practice is a profound form of selfless service:

  • Autonomy, or acting based on one’s values
  • Beneficence, or performing acts of mercy and kindness to all in one’s care
  • Nonmaleficence, or making decisions that inflict the least level of harm and promote the best outcome
  • Justice, or demonstrating equality to every person one meets

Care Management is an Art Form

One of the primary goals of care management is inspiring patients to become partners in their care to provide the roadmap to improved health and knowledge. To do this, Shelley makes a point to emphasize the importance of fostering an environment of direct, open communication.

To the best of their ability, care managers must keep appointments or phone calls and show consistency. When a patient knows that check-ins are coming and they will be asked about their activity or diet, for example, it helps them stay accountable.

Understand the Common Pitfalls to Avoid Them

To conclude the presentation, Shelley shared six models of care management “pitfalls” organizations should avoid and use to restructure and refocus staff energies.

  • The “Short” model: Failing to understand that change takes time and is a long-term investment. Care management will initially start with the highest-risk, highest-cost patients who can be challenging to engage, and it can take longer to see a return on investment.
  • The “Narrow” model: Focusing solely on disease management, which can result in overlapping efforts and patient confusion if multiple care managers reach out to them. In a worst-case scenario, a patient can disengage completely.
  • The “Never Graduates” model: Failing to manage high-needs patients effectively so that they remain a rising risk for recurring ER visits and hospital admissions and never transition out of the cycle.
  • The “Missed the Mark” model: Having inaccurate data that affects risk stratification, causing a misalignment of goals and staffing models. This often results in wasted time and operational inefficiencies.
  • The “Missed the Window” model: Missing critical data due to time delays that limit appropriate intervention. The longer the time delay, the less likely it is that a care manager can make a positive impact.
  • The “Eyes Too Big for the Stomach” model: Having a noble desire to try and impact everyone at once. Without understanding the time and dedication needed per patient, it can be easy to assume that just five care managers can manage 5,000 high-risk patients, but they will not be able to do so effectively.

Watch Shelley’s Webinar in the Education Center

For those who could not join us in early May, Shelley’s webinar is available in the Lightbeam Education Center to view. For more information on clinical transformation and care management with Lightbeam, email

Jessica Scruton

Jessica Scruton, BSN, RN, CCM, is Lightbeam’s VP of Clinical Transformation.

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