✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on June 26, 2025.
Based on the client’s needs and values, the professional case manager collaborates with community-based providers, agencies, and support services to facilitate community-based care, services, and resources that assist the client in achieving and maintaining maximum health and independence.
The collaborative process
Successful collaboration begins with understanding the client’s needs and identifying appropriate resources to meet those needs. The professional case manager:
- Assesses client needs
- Conducts a comprehensive client assessment
- Identifies needs
- Prioritizes needs
- Considers client preferences and barriers
- Identifies, researches, and evaluates appropriate community-based providers and organizations
After a CM identifies potential resources to meet the client’s needs, they verify the availability, scope, eligibility requirements, and referral or application process.
Potential resources may include healthcare providers, which could include:
- Primary care providers
- Mental health providers
- Home health agencies
- Rehabilitation specialists
- Behavioral health specialists
- Clinics
Resources may also include community and support service organizers (described under Community Services and Resources below).
- Coordinates collaboration
Once it has been confirmed that the client is eligible to receive a resource and it will meet the identified needs, the CM:
- Links the client with providers and/or resources
- Coordinates services
- Facilitates communication
- Monitors service delivery and outcomes
- Addresses barriers
- Documents
Community services and resources
Many nonmedical needs, such as home modifications, caregivers, healthy meals, and transportation to medical appointments, are not covered by insurance. The CM arranges community resources to address these needs.
Fraternal and religious organizations provide a range of services, from building wheelchair ramps to operating food pantries. Local communities and nonprofits often operate programs for transportation to medical appointments. Tools like Findhelp.org (formerly AuntBertha.com) help CMs identify and access free or reduced-cost social services by ZIP code. Within the platform, the CM can view program details, make referrals, and monitor their clients’ progress in accessing support.
Commonly used support service organizations
- Area Agency on Aging
- Social service agencies
- Faith-based organizations
- Disease-specific organizations (e.g., American Cancer Society, MS Society, National Kidney Fund, Alzheimer’s Association)
- Housing assistance programs
- Food resources (e.g., food banks and Meals on Wheels)
- Transportation services
- Employee assistance programs
- Public health departments
- Charity organizations (e.g., United Way)
- Service organizations (e.g., Rotary, Elks, Lions Club)
Area Agency on Aging
The Area Agency on Aging can be especially helpful for case managers. It’s a clearinghouse designed to assist people aged 60 or older and people with disabilities to remain in their homes and communities for as long as possible by providing services in the five categories below.
This article includes material from CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025). For more details on this topic and related concepts, visit CCMCertificationMadeEasy.com to purchase your copy.
