Q&A: Conducting patient assessments

Q: What should my staff focus on when conducting case management patient assessments?

A: The assessment is the fact-finding mission. It involves gathering data from the patient, the medical record, claims records, employers, emergency department staff, and behavioral health records. This process is critical to assessing for actual and potential risk of a patient. The assessment process and the sources used will vary depending on the setting of the population health model, but the idea is to be as thorough as feasible. 

The case manager may also contribute to the larger population health database by capturing statistics on the patients he or she assessed, clarifying the inherent risk within the population. Many electronic medical records are created to pull aggregate data from individual assessments. Therefore, detailed accuracy is necessary for the individual patient profile as well as the profile of the population. The case management assessment must contain objective data such as demographics, documented diagnoses, and laboratory and diagnostic results. The case manager will need to confirm patient demographic data such as address, phone number, and support systems. For many patients, this data may change frequently, so the case manager must perform regular assessments, as maintaining accurate data is critical for continuity of care.

The assessment must account for the patient’s cultural, linguistic, and educational needs as well as those of the family and caregivers (CMSA SOP, 2016). The Case Management Society of America (CMSA) Standards of Practice provides a comprehensive list of components that may be included in the case management assessment. The list is all inclusive, and case managers should be careful not to conduct an assessment based solely on whatever components an organization or the medical home may feel is necessary. The more thorough the case manager is, the better for the patient. 

For more information, see Case Management Guide to Population Health: Management Across the Continuum of Care.

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