What I Learned About Case Management in a Community-Based Setting

In my experience, some of the best outcomes happen when client advocacy professionals work together across settings and across disciplines. My career has shown me that the case management skill set has always had value far beyond traditional clinical environments.

My path into this work has never been limited to just one title. I have worked in case management, training, rehabilitation counseling, workers' compensation, disability management and community-based support, and over time, I came to understand that the principles behind the CCM^® are as valuable in homes and communities as they are in more traditional systems of care. People need client advocacy professionals who recognize how to communicate with people of all races, educational and economic backgrounds. 

This reinforced what I already understood: case management is not just about what happens in a hospital, clinic or office. It is about assessment, coordination, problem-solving, communication and persistence helping people to build safer, more independent and stable lives.

One of the more memorable examples of community support alongside case management that has stayed with me was when I worked with a young paraplegic individual who was living in a nursing home. To coordinate home and community-based support, I coordinated with property managers, furniture stores, utility companies, churches, social service programs, and home health agencies to help ensure a safe transition into the community. The successful transition only happened because many people were working towards the same goal: assisting, supporting and empowering the client with a successful transition into the community.

Community health workers (CHWs) are an important part of the broader picture of client care because they bring trust, presence and local knowledge that can strengthen care in real and practical ways. Case managers often focus on care coordination, system navigation, and service planning, while CHWs build trust within the community, engage clients on a personal level and ensure their voices are heard. Together, they collaborate to bridge gaps that optimize the client experience and outcomes, as illustrated in a recent webinar produced by The Commission. It features Julie Smithwick, MSW, CHW, and offers a helpful look at how Board-Certified Case Managers and community health workers can strengthen that kind of community-based support in practice. 

Looking back, I see that I was bringing case management principles into home and community-based work all along. The CCM skill set has never been limited to traditional clinical settings. It has always been about understanding people, navigating systems, building relationships, coordinating support and helping individuals move toward greater stability and independence.

Today, as we talk about client advocacy professionals and the need for a future-ready workforce we have an opportunity to recognize that this work occurs in all settings in which case managers and CHWs practice. As technology and AI contribute to shape the future of care, the focus remains the same: knowing the community, listening to people, and helping them access the support they need to live with dignity and self-determination.

As healthcare systems continue to evolve, collaboration between case managers and community health workers is essential. I have seen, time and again, that meaningful outcomes for our clients depend on people working together across settings, disciplines and communities.