RN Case Manager Self-Assessment Tool
Note: Shaded behaviors within the domains denote behaviors that also apply to the “Contribution” domain;
***behaviors within the domains denote behaviors that also apply to the “Coordination” domain
Role Entry/Competent
Expert
Mastery
Comments
Domain: Clinical Thinking and Judgment Ability of nurses to use their clinical knowledge to affect patient outcome. It incorporates clinical reasoning, which
includes clinical decision-making, critical thinking, and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating
formal and experiential knowledge.
Practice is guided by policies,
procedures, and standards and is
driven by theory and experience.
Within department guidelines,
assesses multi-dimensional factors
(physiological, psychological,
social, economic, and spiritual) of
the patient/family for anticipated
needs post point of service.
Clinical Assessment and Analysis
Practice relies on previous
Practice is driven by an intuitive
experience for focused analysis of
base and is self-directed, flexible,
problems and solutions with
and innovative.
individual patient modification in
order to meet outcomes.
Independently and consistently
performs goal-focused and
individualized assessment when
planning for discharge, including
those with complex
pathophysiological and
psychosocial needs.
Exhibits highly developed
assessment abilities that exemplify
a comprehensive understanding of
the patient/family situation and
discharge needs.
Identifies and recognizes actual and Incorporates population-specific
potential needs for care transitions. needs related to care transitions.
Able to readily identify discharge
needs of even most
complex/catastrophic patients.
Identifies and assures that the
patient meets criteria for current
patient classification
Based on depth of knowledge with
system and patient populations,
utilizes processes to secure needed
changes in patient classification.
Identifies expected outcomes and
interventions needed to meet
identified discharge needs and
maintain standards of practice.
Proactively responds to the need
for reclassification (I.e.,
observation to inpatient status) and
appropriateness of level of care.
Development of Discharge Plan
Accommodates unplanned events
Is consistently effective in creating
and evaluates /responds
a holistic discharge planning that
appropriately with speed,
ensures quality outcomes even in
efficiency, flexibility and
the most challenging discharge
confidence.
situation.
Approved February 2015 Joint Implementation Team
RN Case Manager Self-Assessment Tool
Demonstrates basic recognition of
barriers to effective and timely
discharge.
Develops, coordinates, and
evaluates a safe and effective plan
of care with resources available.
Utilizes interprofessional rounds to
facilitate discharge plan.
Recognizes barriers to effective
discharge and proactively
addresses them.
Anticipates and prevents potential
barriers.
Facilitation/Implementation/Evaluation of Discharge Plan
Proactively monitors progress
Refers facets of the care plan
toward the goals of the plan and
beyond the control or influence of
makes revisions in response to
the team to the appropriate level of
changes in patient needs and
authority.
condition.
Facilitates and coordinates case
conferences to manage challenges
with discharge plan of care.
Utilizes Health System resources to
resolve conflict or challenges
regarding treatment decisions, if
they occur.
Domain: Systems Thinking Appreciating the care environment from a perspective that recognizes the interrelationships that exist within and across
health-care settings.
Utilization Review and Management
Has current knowledge of
Advocates for the patient while
Teaches/coaches others related to
utilization management: Patient
balancing stewardship for the
utilization review process. (I.e.
classification, level of care, length
organization and prudent
making calls, UR process,
of stay, insurance, regulatory
management of resources.
Physician Advisor group, roles
bodies, and CMS Guidelines.
related to UR)
Recognizes and collects data
related to avoidable days/delays.
Learns patient/family story, goals,
resources, and the meaning of
illness/health care episode in the
Proactively prevents medical
Participates in the development of
necessity denials through education performance improvement activities
of physicians, staff, and patients,
relevant to avoidable days/delays.
interfacing with payers and
documenting relevant information.
Discharge Planning
Identifies inconsistencies or gaps in Recognizes situations that require
patient/family story and utilizes
referral to risk management (Office
internal and external resources to
of Clinical Safety), Protective
Approved February 2015 Joint Implementation Team
life of the patient.
RN Case Manager Self-Assessment Tool
verify and/or complete story.
Services and assures referrals are
made in a timely manner.
Collaboratively develops and
implements transition plan with
patient/family and interprofessional
team.***
Participates in policy, procedure,
Lead/participate in the development
and process development or change of standards for care management.
for care management.
Identifies, addresses,
communicates, and documents
actual and potential safety issues
during and post transition of care,
including patient referrals.***
Ensures that patient story and goals
are adequately communicated
through telephone calls and/or
electronic referrals.***
Highly individualized
understanding of actual and
potential needs post-discharge even
in most complex cases, addressing
needs in multiple, creative ways
with community resources and
providers.***
Recognize need for onsite
education of and/or evaluation by
the external providers and case
managers, as appropriate.***
Educates external providers and
case managers, as appropriate, and
engages them in case conferences
and/or care coordination.***
Negotiates with payer sources and
hospital finance to achieve
effective plan within resources.***
Utilizes escalation processes (I.e.,
contracting) as needed.***
Knowledgeable about cost, payer
sources, and system resources.
Identifies patients who are at risk
for readmission.***
Applies interventions to
proactively prevent
readmission.***
Care Coordination
Intuitively identifies patients and
populations at risk for readmission,
and implement strategies for
improvement (I.e., Complex Case
Management, Insurance Case
Manager).***
Domain: Advocacy Working on another’s behalf, representing the concerns of the patient/family/community, and serving as an agent in identifying
and helping to resolve ethical and clinical concerns within the clinical setting.
Patient/Family Involvement in Decision-making
Approved February 2015 Joint Implementation Team
Recognizes, respects, and supports,
and supports patient/family rights
and maintains confidentiality.
Aware of UMHS patient rights and
responsibilities.
Knows, understands, and honors
patient’s goals for discharge plan.
Develops a plan for the day and
plan for the stay that is based on
patient goals.
Assures that patient receives
information on benefits and costs
related to current stay and postdischarge care and services.***
RN Case Manager Self-Assessment Tool
Promotes patient’s selfAdvocates and facilitates on behalf
determination in all decisions,
of patients and families for service
honoring that right even when
access or creation, and for the
decisions differ from
protection of the patient’s health,
recommendations of the healthcare safety, and rights.***
team, and assists the health team’s
understanding of and respect for
Recognizes limitations to patient’s
the patient’s decisions.
autonomy preventing imminent
danger to the patient or others.
Goal Setting
Identifies critical elements of
Evaluates patient/family’s level of
patient story in order to
understanding and comfort with
collaboratively and optimally
progress towards goals and
facilitate patient/family goal setting potential need for goal revision.
for transitions of care.
Identifies multidimensional
(physiological, social, and spiritual)
factors and integrates into ongoing
goal setting and individualized plan
of care.
Advocacy with Payers
Negotiates with payers regarding
Identifies trends and issues in payer
available options for transitions of coverage that impact patient service
care and informs patient of
delivery and works to resolve them
risk/cost/benefit of all options.*** at individual and system levels.***
Domain: Therapeutic Relationships/Engagement A constellation of nursing activities that are responsive to the uniqueness of the patient and
family and that create a compassionate and therapeutic environment with the aim of promoting comfort and preventing suffering
Therapeutic Communication
Individualizes communication
Consistently role models
Intuitively uses therapeutic
based on assessment of patients and individualized therapeutic
communication with patient/family.
families.
communication based on patient
and family needs.
Approved February 2015 Joint Implementation Team
RN Case Manager Self-Assessment Tool
Possesses clarity on one’s own
Identifies when peers and team
Challenges and moves to resolves
values and how they affect
members’ values and beliefs affect team biases utilizing appropriate
interactions, relationships and
their clinical judgment and
resources (I.e. Ethics Committee) as
boundary setting, incorporating that patient/family care.
needed.***
understanding into patient/family
interactions.
Demonstrates empathy in
interactions with patients and
families.
Invites patients and families to
actively participate in plan of care
to foster growth, competence, and
self-efficacy.***
Caring Practice and Engagement
Plans and provides care
Proactively anticipates
management actions that promote
patient/family response and
intentional caring.
provides creative approaches to
optimize comfort and support.
Empowerment
Maximizes patient/family
Identifies and actively engages
participation in decision-making
patient/family strengths and
and goal setting along the
expertise and motivates them to
continuum to ensure and advance
implement the plan towards a
the plan of care to support
successful transition.***
successful transition to the next
level of care (I.e. care conferences
and other practices).***
Domain: Collaboration/Communication, and Professional Relationships Working with others in a way that promotes and encourages each
person’s contributions. It involves inter- and intra-disciplinary work with colleagues and ability to negotiate and resolve conflict.
Valuing Teams/Teamwork
Engaged, active team member and Fosters mutual regard, respect, and Demonstrates team values that
leader.
trust within the team.
motivate people to care about the
performance and success of others.
Recognizes role of each member of
the interprofessional team.
Demonstrates empathy and
Is sought out by members of the
interprofessional health care team.
Creates conditions and
relationships that promote creative,
Through shared values and a clear
professional identity, demonstrates
and role models an interprofessional
collaborative approach to patient
care.
Approved February 2015 Joint Implementation Team
compassion in interactions with
team members.
Approaches conflict situations in a
constructive manner.
Provides and accepts feedback with
a positive approach.
RN Case Manager Self-Assessment Tool
innovative, and positive processes
and outcomes.
Negotiation/Conflict Resolution
Fosters other’s development of
Recognizes value of conflict in
conflict resolution skills.
individual and organization learning
and growth.
Employs conflict resolution skills
in maintaining relationships and
resolving challenging situations
(I.e., Crucial conversations)s
Employs negotiation skills in
building and maintaining
relationships and resolving
challenging situations (I.e., mutual
gains, interest-based)
Domain: Facilitator of Learning and Professional Development The competency in facilitating patient, family, and staff learning. This includes
supporting a learning environment characterized by safe discourse, mentoring, and team development. Teaching, along with patient and family
learning, is embedded in care.
Patient/Family
Identifies patient/family level of
understanding of their disease
process, and care needs.
Identifies patient and family ability
and willingness to learn and
considers preferred way to learn
Incorporates preferred learning
style/way to learn in order to
maximize patient/family education.
Evaluates responsiveness to
education, including understanding
and psychomotor skills.
Assures individualized educational
plan is in place.
Monitors progress toward goals of
educational plan and work with
appropriate team members to
modify as necessary.***
Mobilizes resources for learning
needs in order to address even the
most challenging situations post
discharge.***
Ensures that education regarding
disease process and care needs has
been provided by the appropriate
members of the health care
team.***
Identifies inconsistencies in
education provided, and works to
clarify and resolve for
patient/family prior to
discharge.***
Serves as expert resource and
facilitates other staff in improving
patient education.
Collaborates with other disciplines
Approved February 2015 Joint Implementation Team
RN Case Manager Self-Assessment Tool
to develop and/or implement
patient/family educational materials
and teaching programs.
Provides basic information
regarding level of care, resources,
insurance, and community
resources.
Identifies gaps in knowledge of
team members that affects their
ability to provide effective care to
the patient/family.
Nurse/Interprofessional Team
Provides information to the
Able to share comprehensive, ininterprofessional team regarding
depth perspective on level of care,
available resources and insurance
resources, insurance, and
benefits for acute and post-acute
community resources from preservices.***
admission to discharge, including
the most complex patients.***
Conducts and provides inservices
and/or participates in orientation of
new staff members.
Able to provide “just in time”
teaching as needed for complex
cases and/or unanticipated
outcomes.
Creates staff education tools.
Mentors and develops the
leadership qualities of others,
including advancement in the Role
Specific Advancement Model.
Maintains current knowledge of
case management, utilization
management, and discharge
planning, as specified by federal,
state, and private insurance
companies.
Identifies own learning needs and
sets goals for knowledge/skill
enhancement within the practice
setting.
Self
Attends conferences and other CE
Demonstrates evidence of
offerings in order to educate self
advancing professional identity (at
regarding current practices and
least one):
trends.
 Certification (I.e., ACM;
CCM, other specialty)
 Advancing education (I.e.,
Master’s Degree)
Sets goals for knowledge/skill
 Active participation in
enhancement within and beyond
professional organization
the practice setting.
(I.e., ACMA; MNA)
Approved February 2015 Joint Implementation Team
Attends inservices, department
continuing education, and staff
meetings.
Participates in department
continuing education offerings.
RN Case Manager Self-Assessment Tool
 Active
Holds department and/or hospital
membership/leadership role
wide committee membership.
in institutional groups
related to nursing or patient
care
 Speaking, media exposure,
publishing, policy making
Completes all mandatory programs.
Domain: Response (responsiveness; sensitivity) to Diversity: The sensitivity to recognize, appreciate, and incorporate differences in the
provision of care. Differences may include, but are not limited to, individuality, culture, spiritual beliefs, gender, gender expression, sexual
orientation, race, ethnicity, family configuration, lifestyle, socioeconomic status, age, values, etc.
Patient/Family
Aware of and values the diversity
Demonstrates actions that
Embraces visible and invisible
in patients and families,
incorporate the rich traditions,
diversity; seeks out perspectives
incorporating diversity
beliefs, and values of patients and
from those of different backgrounds
considerations in patient care.
families in relation to transitions of and cultures.
care.
Seeks to learn about and optimize
Integrates understanding of
the unique contribution inherent in Advocates for culturally competent populations into patient care.
the diversity and culture of each
plan of care.
individual.
Models and teaches responsiveness
Assures all communication is nonto diversity and holistic care.
judgmental and sensitive to cultural
differences within the environment.
Aware of and values diversity in all
members of the health care team.
Professional Relationships
Promotes group norms that
Depends on and utilizes the
demonstrate valuing of all health
diversity of workforce to enrich and
care team members.
build highly effective teams.
Recognizes own biases and
demonstrates empathy as a member
of the health care team.
Domain: Advancing Practice An ongoing process of questioning and evaluating practice, provide informed practice, and creating practice
Approved February 2015 Joint Implementation Team
RN Case Manager Self-Assessment Tool
changes or innovation through research utilization and experiential learning.
Evidence Based Practice (EBP)
Demonstrates an awareness of
Independently seeks out
Evaluates effectiveness of Evidence
current literature in care
opportunities to share and
Based practice changes.
management.
influence evidence based practices
in care management (I.e., Journal
Club, Staff Meeting, Newsletter,
forums).
CQI/Innovation/Research
Collects data to support quality
Participates in Continuous Quality Leads CQI projects from initiation
initiatives and concerns.
Improvement projects relevant to
through conclusion.
care management and/or clinical
specialties.
Identifies trends and areas for
quality exploration.
Domain: Contribution (Designated within domains with shading)
Domain: Coordination (Designated within domains with ***)
Comments:
Signature:
Date:
Approved February 2015 Joint Implementation Team