key: cord-0923376-6ta0be0m
authors: Tahan, Hussein M.
title: Essential Case Management Practices Amidst the Novel Coronavirus Disease 2019 (COVID-19) Crisis: Part 2: End-of-Life Care, Workers' Compensation Case Management, Legal and Ethical Obligations, Remote Practice, and Resilience
date: 2020-06-15
journal: Prof Case Manag
DOI: 10.1097/ncm.0000000000000455
sha: 84a188a1f48c9b24e8c44d07e3cda318fbb87c0c
doc_id: 923376
cord_uid: 6ta0be0m

OBJECTIVES: This is the second of a 2-part article that discusses essential case management practices and strategies amidst the novel coronavirus disease 2019 (COVID-19). The series showcases the potential professional case managers have in support of managing during a crisis such as a global pandemic. Part II continues to describe reenvisioned roles and responsibilities of case managers and their leaders to meet the needs of patients/support systems during the crisis. It focuses on the increased need for end-of-life care, impact on workers' compensation case management practice, and the self-care needs of the professional case manager. PRIMARY PRACTICE SETTINGS: Applicable to the various case management practice settings across the continuum of health and human services, with special focus on acute care. FINDINGS/CONCLUSIONS: The COVID-19 global pandemic has resulted in a crisis case managers and other health care professionals never faced something like it before. At the same time, it has provided opportunities for innovation and creativity including use of digital and telecommunication technology in new ways to ensure the continued delivery of health and human services to those who need them regardless of location. It has also resulted in the development of necessary and impactful partnerships within and across different health care organizations and diverse professional disciplines. Most importantly, this pandemic has required special attention to the increased need of patients for timely palliative and end-of-life care. In addition, it has prompted a focus on the safety, health, and well-being of case managers and other health care professionals, resulting in expanded workers' compensation case management practice coupled with the need for self-care and resilience. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Professional case managers are integral members of interprofessional health care teams. Their roles and responsibilities are even more necessary during the uncertainty of a global pandemic such as COVID-19. So far, the experience of this crisis has resulted in a deliberate need to ensure the safety of both, those who are the recipients of health care services and those who are responsible for the provision of care. Self-care and resilience of health care professionals and case managers, especially due to the complex dynamics of the COVID-19 pandemic, have advanced a desirable and necessary view of remote/virtual practice and as a strategy for enhancing the person's health and well-being. This pandemic has forced the development of impactful partnerships and collaborations among the diverse contexts of health care organizations and support service providers. These contexts of care delivery have also emphasized the necessary legal and ethical practice of case managers and the other involved parties. Experts agree that the innovative care delivery methods practiced during the pandemic will undoubtedly remain as desirable beyond the current crisis period.

about feelings of fear, anger, anxiety, frustration, and apprehension. They also have given rise to innovation, creativity, engagement, resilience service to others, and a sense of community. Like our society and the community at large, our health care industry has also experienced similar dynamics that have caused the development of innovative and new ways to the provision of care to patients and their support systems; for example, use of telehealth, virtual specialty consults, and remote primary care visits. Professional case managers have also expanded the use of telecase management services to reach patients and their support systems regardless of where they are (e.g., at home) and across the continuum of health and human services. They have done this via collaborations among various health care organizations and diverse interdisciplinary health care professionals. These have extended to different levels of care and to collaborations among public and private health care organizations and community-based support service providers.

Health care organizations and providers, including case managers, have been in the center of the COVID-19 pandemic along with other support service agents working tirelessly to provide timely access to health and human services for those in need. They have demonstrated cooperative, collaborative, and accountable behaviors that have enhanced already existing partnerships and created new and necessary ones to ensure availability of health care resources in an environment that must promote safe and quality care. Simultaneously, however, these constituents have also needed to maintain their own health status (physical, mental, and emotional), safety, and well-being by adhering to complex procedures of infection precaution to prevent exposure to, and the transmission of, this highly contagious disease. Interestingly, however, they have had to do this while needing to adapt to conservation strategies of personal protective equipment (PPE) due to supply shortages and recommendations of professional societies and government agencies. Concurrently, they also have had to follow standards of care with fl exibility and understanding that these also will be changing constantly as new understandings of the disease process are gained. Therefore, surviving in a practice environment of uncertainty requires adaptive mind-sets, attitudes of resilience, embracement of vulnerability, and agile footing. Effective case managers are known to demonstrate similar qualities in their practice; they are also comfortable with the need to be adaptable because they have had prior experience of managing unique challenges in the design of safe care (and transitions of care) plans for patients/support systems with unusual needs and amidst uncertain courses of treatments and prognoses.

Case management leaders and professionals are at the crossroads of demonstrating engagement and accountability with their fellow health care leaders and providers in responding to the COVID-19 global pandemic and its crisis nature. Although it is tempting to take a disempowered stand toward this pandemic and its increased number of challenges (social, personal, fi nancial/economic, and professional) we have been facing daily for the past several months, it is rather important to confront these challenges in an empowered manner. Without hesitation, as leaders and health care professionals, including case managers, we must play an active role in protecting everyone's life and mobilize appropriate resources and personnel in new ways to ensure the provision of safe, quality, necessary, timely, compassionate, and patientcentered services all while being kind to ourselves. Amidst these challenges, a lot of learning and creativity has been taking place as well. We must celebrate these modifi ed ways of practicing our various professions and consider their continuation after the intense pandemic period is over. The various members of the interdisciplinary health care teams at the diverse organizations across the continuum of care have had to face redeployment to assume different and expanded duties. Along the same lines, government agencies such as the Centers for Medicare & Medicaid Services (CMS) have relaxed some of their regulations, allowing for fl exibilities in utilization management and discharge planning procedures (CMS, 2020a) . They also have been open and forthcoming with information and the sharing of care guidelines for the betterment of everyone: providers, consumers, or payers for health care services. Changes such as these have contributed to an increased focus on the actual delivery of care to patients and their support systems and in nontraditional ways. They also have So far, the experience of this crisis has resulted in a deliberate need to ensure the safety of both, those who are the recipients of health care services and those who are responsible for the provision of care.

Experts agree that the innovative care delivery methods practiced during the pandemic will undoubtedly remain as desirable beyond the current crisis period.

resulted in impactful collaborations across health care organizations, providers, and other communitybased support service agents to better serve the consumers of health and human services. Professional case managers during this COVID-19 pandemic are having a great opportunity to exercise their educational backgrounds, and knowledge, skills, and competencies in the provision of case management services to the full extent of their licenses and scopes of practice. They are caring for patients with complex COVID-19 conditions and needs while ensuring that the non-COVID-19 patients and especially those with multiple chronic or newly emerging conditions receive timely care. After all, case managers' primary role is patient/support system advocacy, which remains a priority even during this crisis where priorities may have turned upside down. This twopart article series highlights several key strategies and areas of impact for the case management professionals and leaders whether directly or indirectly involved in the COVID-19 crisis. Discussing COVID-19 as a disease, diagnostic procedures, prevention strategies, and treatment options are not within the scope of this series. For such information, one may visit the Centers for Disease Control and Prevention (CDC) website where detailed guidance can be found ( https:// www.cdc.gov/coronavirus/2019-ncov/index.html ).

Part I of this two-part article started to address the key roles and responsibilities professional case managers and their leaders may play during a crisis such as the COVID-19 pandemic ( Tahan, 2020 ) . Part II continues this discussion. Part I discussed the provision of essential health and human services for patients and their support systems while challenged with promoting ongoing safe environment of care for both the patients and the health care professionals alike. It also highlighted important ways telehealth, telemedicine, and tele-case management can be applied to ensure continued availability and for timely delivery of health care services. It showcased the value of virtual and remote sites of care in meeting the health care needs of individuals whereas traditional primary care sites have needed to close because of the unusual dynamics of the COVID-19 disease. Moreover, Part I described key roles of professional case managers amidst patient surge capacities in the acute care settings whereas long-term care facilities faced unprecedented challenges that required them to treat in place and make certain health care services, usually not within their scope, available to their residents (patients). These dynamics emphasized the value of case managers' roles in discharge planning, transitions of care, care coordination, and interprofessional collaborations while continuing to practice patient/support system (person)-focused care delivery. The fi nal feature of the impacted practice included in Part I was the reality of redeployment of case management personnel that presented an opportunity for case managers and leaders to contribute to meeting the demands of this crisis. Part II of this two-part article continues to describe the various contributions of case management practice amidst the COVID-19 global pandemic and their impact on both the practice and lives of case managers. This current part highlights the value of palliative and end-of-life care, especially for patients who are critically ill, and the innovative ways of making such service available while ensuring a quality and dignifi ed death. In addition, workers' compensation and return to work are discussed because of the importance of maintaining the health, safety, and wellness of those involved in the delivery of care to patients/support systems under the conditions of the COVID-19 pandemic. Workforce/ workplace health and safety are uniquely important because of the increased chances of exposure of health care workers to COVID-19, requiring quarantine and follow-up care. Moreover, in Part II, two other aspects of professional case management practice have gained increased recognitions as opportunities to counter the effects of the health risk in the workplace environment and the emotional and psychological strains of COVID-19. These are the rise of remote/virtual case manager's practice and self-care and resilience due to the uncertain dynamics of this infection and reports of health care workers feeling emotionally drained. As in any optimal health care practice, the last point this part covers must focus on a view of the provision of legal and ethical case management services during the COVID-19 pandemic.

Surviving in a practice environment of uncertainty requires adaptive mind-sets, attitudes of resilience, embracement of vulnerability, and agile footing.

The ongoing uncertainty and fast and constantly changing dynamics of this global pandemic have brought about feelings of fear, anger, anxiety, frustration, and apprehension. They also have given rise to innovation, creativity, engagement, resilience service to others, and a sense of community.

As of May 2, 2020, the Coronavirus Resource Center at the Johns Hopkins University and Medicine (JHU) has reported that more than 3.4 million people worldwide have suffered from COVID-19 and 242,296 individuals have died from the disease (mortality rate of 7.11%). In addition, and as important to report and celebrate, nearly 1.1 million (32%) people worldwide have been reported to recover from the disease. This global pandemic has continued to infl ict more than 200 countries to varying degrees, some more seriously than others ( JHU, 2020 ). These data points refl ect only the confi rmed cases-primarily those who sought out health care services, resulting in formal registration and reporting of the incidence. Experts agree that the incidence of this infection must be much greater than the reports have refl ected so far due to concerns of not enough testing for COVID-19 have been made available, combined with the fundamental problems in self-reporting where it is likely that some individuals may have felt their symptoms were less serious and controlled, never accessed a health care setting for care, and therefore their conditions have remained unreported. Experts also agree that the incidence of COVID-19 has continued to rise globally in the absence of essential medical treatments such as vaccination and pharmaceuticals. In the United States, the reports as of this writing refl ect nearly 1,126,520 of confi rmed cases and more than 66,000 deaths (mortality rate of 5.86%) ( JHU, 2020 ). The COVID-19 global pandemic has infl icted virtually every state in the United States to varying incidence rates and depending on the population density and type of region (i.e., urban, suburban, and rural). Table 1 lists the top 10 states based on confi rmed cases and their corresponding deaths and mortality rates. COVID-19 global dynamics based on the experience so far have been described as pervasive, devastating, and pernicious, and there are a lot more aspects to the disease for health care professionals to understand. One that has been clear is the importance of public health in controlling this disease-the socially based and human behavior-dependent interventions implemented to date have contributed to a decline in the spread of the infection. Examples of such interventions are physical distancing, self-quarantine, hand hygiene, use of PPE such as a face mask, limitations of public gatherings, travel restrictions, and self-monitoring for symptoms of the disease and ultimately pursuing early access to health care services. The essential role case management and professional case managers may play in responding to the COVID-19 pandemic, the topic of this article, is invaluable for both the public and fellow health care professionals. The two-part article series emphasizes the importance of innovation, "out-of-the-box" thinking, and the power of partnerships and collaborations resulting in recognition of new sites of care and associated roles for case managers and other health care professionals.

Under usual circumstances, provision of patient care at the end of life is a challenging and stressful occurrence for the various members of the interprofessional health care team, including professional case managers and patient/support systems, with no exception. It is even of greater concern amidst the COVID-19 crisis where these health care professionals are challenged to maintain the provision of quality, safe, and timely access to necessary services, including palliative care, to patients and their support systems. This is coupled with simultaneously being asked to limit the number Although it is tempting to take a disempowered stand toward this pandemic and its increased number of challenges (social, personal, fi nancial/economic, and professional) we have been facing daily for the past several months, it is rather important to confront these challenges in an empowered manner.

of individuals who come in contact with the patient (both health care professionals and patient support system/family members) in an effort to reduce the risk of exposure to the virus and ultimately disease transmission. Clinicians have noted that the acuity of health conditions of the COVID-19-positive patients or those under investigation and the intensity of required services and resources vary along a continuum of low to high complexity and intensity. They also note that the patients' conditions may deteriorate suddenly, resulting in a severe acute care crisis.

In addition, such progression in acuity is not easy to anticipate or proactively prepare for, neither as an interdisciplinary health care team member nor as a patient or patient's support system. The dynamic, uncertain nature and nonspecific clinical presentation of COVID-19 have made care planning, the course of treatment/interventions, and coordination of services a challenge for the health care team and case managers. These also have presented unusually emotional and stressful situations for the patients and their support systems. For the case manager especially, anticipating a timely and effective coordination of services, advocating for the patients and their support systems, participation in formal interprofessional patient care management rounds, and brokering of resources have become of unique concern. The usual issues of palliative care and end-of-life care, whether patient's quality of life, agreed-upon patient/support system care goals, advance care planning, pain and symptom management, or support for the patient's caregiver(s) remain relevant during the COVID-19 crisis. However, these concerns have taken an unusual turn and have escalated in their magnitude because of the sudden and uncertain need for initiating an end-of-life care goal discussion with the patient and/or the support system. Regardless, palliative care and ethics consults have never been more essential in care planning for such patient population-Patient needs amidst the COVID-19 crisis should not be addressed any less or differently from other crisis events occurring under normal disease progression pattern and need for terminal care. Case managers, as patient advocates, are perfectly positioned to facilitate the necessary palliative care or end-of-life care conversation, including advance care planning and securing the essential legal documents that clearly note the patient and support system wishes and care goals (see Table 2 ).

What is different for the professional case manager in the COVID-19 situation is the limited ability to initiate the palliative or end-of-life care planning discussion, including hospice care. This concern also extends to obtaining informed consent, encouraging shared decision-making, and facilitating an opportunity for convening a routine interprofessional or interdisciplinary care management conference that is attended by the patient/support system and the essential team members whether physically or remotely present. Although care team rounding is essential at any time

Essential Palliative and End-of-Life Care Activities for Case Managers During COVID-19 Crisis • Coordination of an ethics and palliative care consult whether direct in person or via telehealth/tele-consult approach. • Facilitation of a patient/support system care conference, if possible, to secure agreement on palliative care or end-of-life care goals and coordination of attendance by the care provider responsible for leading the patient's care. Knowing that an in-person case conference may not be feasible due to physical distancing and visitation restrictions policies, the case manager may arrange for a teleconference, videoconference, or tele-visit by the essential parties. • Raising the need for palliative or end-of-life care and hospice earlier in the care planning process so that such care goal is anticipated and better planned for rather than rushed just-in-time upon sudden change in the patient's condition. Accountability for counseling the patient/support system about advance care planning. • Managing pain, comfort, and symptoms by coordinating the services of the right specialists and to ensure peace and dignity during the time of death. Coordinating a transfer to hospice care as warranted. • Ongoing assessment and reassessment (even if with modified focus on key priorities) of the patient's condition, response to treatments and interventions, and continued appropriateness of the patient's care goals and case management plan for the purpose of alignment of patient/ support system's wishes with the up-to-date plan. • Evaluating the impact of equipment shortages on options for care, especially life-sustaining measures such as mechanical ventilation and hemodialysis machines, resulting in the need to triage patients for alternative plans of care (e.g., palliative care). An example is giving priority for a patient needing mechanical ventilation for exacerbation of a respiratory condition over another patient with multiple comorbidities, poor prognosis or chance of survival, and multiple prior failed attempts at reversal of an acute renal failure situation. In this case, the case manager may directly engage in or facilitate communication with the patients and their support systems regarding the alternate care options. • Facilitating a patient's support system visitation to a patient/loved one because of terminal condition and impending death despite "no visitors policy." Creating opportunities for tele-visits of the patient's support system members during the dying phase to express their goodbyes and final wishes; promote the experience of quality and dignified death. • Staying on the line (telephone, video call, or tele-visit) after a patient's death with the patient's family who may have called to wish their loved one "goodbye." It is important to provide support and help in such a situation, even if just for a moment of silence and reflection in honor of the patient, inquiry about any special wishes, or sharing information regarding what will happen next. • Securing the services of spiritual care team, social workers, and/or counselors to ensure the provision of emotional support and psychosocial and grief counseling. • Documentation of advance care planning (Medical Orders for Life-Sustaining Treatment, Do Not Resuscitate, Do Not Intubate), counseling regarding risks and benefits, informed and shared decisions-making, patient/support system wishes regarding resuscitation and intubation in case of COVID-19 serious symptoms, and provision of spiritual and emotional support.

of a patient's health care encounter and regardless of whether the patient's condition is serious, the reality in a COVID-19 crisis is that such team rounding is not feasible for many reasons, one of which is the mandate of physical distancing and prevention of exposure to the coronavirus. Instead, telehealth and telemedicine platforms are readily available tools, especially in crisis or disaster situations, to connect one health care provider with another or with a patient, regardless of location and when there is a secure connection-one that adheres to applicable privacy and confidentiality laws. In part I of this two-part article, Tahan (2020) described various digital technologies that can be used for the provision of necessary care and tele-case management services. These can be used for the provision of a timely tele-ethics and/or tele-palliative care consult. This remote/virtual approach for specialty consults has gained increased popularity during the COVID-19 pandemic due to its ability to respond to patient needs while preventing the risk for exposure to this infection. Professional case managers may facilitate access to these electronic platforms and coordinate the palliative care or end-of-life care discussion with both the patient/ support system and the interdisciplinary health care team. A significant use in the COVID-19 crisis is for providerto-provider connection concerning a patient's need for end-of-life care in the form of an electronic consultation. Another is remote provider-to-patient connection (televisit) that allows patient evaluation, counseling and recommendation for care planning, implementation of palliative care interventions, or finalizing plans for patient's transfer to the hospice service. These tools of care delivery not only facilitate the provision of timely palliative care by a necessary specialist provider but also limit the number of health care professionals present physically to care for the COVID-19-positive patient, therefore reducing the risk of exposure to the virus and further transmission of the disease. The telehealth tools and workflows also help connect the various specialty services and teams of health care professionals in bringing critical clinical resources to the patient's bedside in a timely manner. These methods of care delivery distribute expertise, minimize patient movement, preserve supplies in a time of shortage, and further mitigate the risk of COVID-19 exposure to patients/support systems and health care professionals, especially during a surge of hospitalized patients.

The need to implement restrictive visitation policies in virtually every health care organization across the country, especially acute care hospitals and longterm care facilities, patient support systems have faced increased concern for not being constantly available at the bedside of their loved ones during the most vulnerable times-the dying phase. Although these health care organizations may have identified the period of end-oflife care as an exception to any enacted restrictive visi-tation policy, they still reinforced a limited visitation practice. The policy may have identified a designated caregiver only to visit and for a limited time compared with liberal visitation policies in place before the COVID-19 pandemic. This change in practice has prevented multiple family members and friends from visiting the dying patient to bid their goodbyes and gain closure and as a result, although unintentionally, may have contributed to the dying patient feeling alone and isolated at the time of death. Professional case managers and other health care leaders have been innovative in the strategies they have implemented to ensure quality and dignified death. For example, they have developed protocols about the use of available interactive digital telecommunication and video-chat technology in the care of patients during the dying phase, regardless of whether the dying patient is receiving care in a critical care or a medical-surgical unit. The use of such available technology has provided the patient and the support system a sense of relief because of the opportunity created for them to connect and express their last wishes and to be present together, even if remotely, during the patient's time of death. With this practice, case managers and other health care professionals have been able to incorporate tele-visits by patient's support system members as a key intervention in the case management plan of care. They also have expressed their caring, compassion, and empathy to their patients and support systems.

Like any other infectious diseases, the COVID-2019 has presented health care professionals and workers with an increased risk for exposure due to its contagious and uncertain nature. Workers' compensation teams in any health care organization have always focused on the health and safety of the workforce and the workplace. Risk mitigation strategies these teams routinely engage in may vary by organization and the available resources. Examples include completing an assessment of risk (routine and for a cause such as COVID-2019), monitoring (or surveillance) of the practice environment, work restriction decisions, workers' fit for duty assessment, return-towork clearance, workers' counseling regarding safety in the workplace, medical or family leaves, and development and implementation of practice-related policies and procedures. These risk-reduction strategies are all applicable in the COVID-19 crisis, however, specifically focused on the dynamics of this unique infectious disease that have been changing almost daily, requiring constant practice readjustment. In this unique situation, workers' compensation case managers are invaluable for reducing workers' fear, anger, and apprehension while facilitating a feeling of resilience. They do this by establishing necessary procedures for health care workers' screening and counseling regarding exposure and managing advice and triage call centers for employees, while implementing new practice standards that address the effective and proactive management and prevention of the inherent risk for disease transmission. In this regard, workers' compensation case managers actively collaborate with other experts such as the infection prevention and control and risk management specialists to build trust in personal and coworker safety as well as the safety of patients and their support systems.

Because of their extensive involvement in the care of, and close contact with suspected or confirmed COVID-19 patients, health care workers (clinicians in particular) are at a higher risk for exposure to and to become infected with this disease than the public. Workers' compensation case managers and other educators provide these health care workers and professionals with detailed guidance and instruction on disease prevention. These health care workers also are considered a priority group for screening and monitoring by the workers' compensation case management teams to proactively intervene before an untoward situation occurs or unnecessarily escalates. Other health care support personnel such as those not directly involved in patient care provision are also provided with the necessary attention despite being at a low risk for exposure. The CDC has established guidelines for the screening, testing, and return to work of health care workers (CDC, 2020a). The Occupational Health and Safety Administration (OSHA) also has developed a set of guidelines for the preparation of workplace/health care practice environment for the concerns of COVID-19 (OSHA, 2020). Workers' compensation case managers should become familiar with these guidelines, act as the primary resource of workforce safety standards, and lead the implementation efforts regarding disease prevention and management at their organizations. They also may collaborate with leaders of the infection prevention and control and infectious disease departments. The CDC recommends a conservative approach in its guidelines for the assessment of risk, exposure screening, testing, monitoring, and work restrictions (CDC, 2020a). The OSHA provides recommendations for infection prevention practices, implementation of administrative, engineering, and work practice controls, effective use of PPE, and the classification of workers' exposure risk (OSHA, 2020) . These together provide an excellent source for standards workers' compensation case managers may use to guide the COVID-19-related workforce health and safety practices at their respective organizations.

From the perspective of usual workers' compensation case management roles and responsibilities, the COVID-19 crisis and the challenges it has presented every industry and employer across the globe may have contributed to a reduction (or delay) in workers' compensation claims. This most likely is a direct result of business closures, implementation of modified work hours and contexts (e.g., remote working models), or less risk of exposure to occupational illnesses. However, it is premature to determine the impact of compensable COVID-19-related workers' compensation claims whether broadly or by industry. It is also a challenge to estimate how the cost of these claims may compare with the pattern of those incurred prior to the COVID-19 pandemic. Although these conditions may be true for some industries, they are not as applicable in health care. On the contrary, the COVID-19 pandemic has contributed to an increased risk of exposure of employees to work-related illnesses and injuries in the health care industry, especially for workers who are directly involved in patient care. Ultimately, the impact of COVID-19 on workers' compensation systems, occupational health departments, and roles of case managers may vary in significance.

Currently, it is unclear how best to estimate the cost of impact of workers' compensation and liability claims associated with COVID-19; however, without a doubt the pandemic has increased the administrative burden for employers, workers' compensation leaders and case managers, and work environment concerns for the workers, with the impact being much more significant in the case of health care organizations. For a COVID-19 pandemic-related occupational illness or injury a worker may claim to be eligible for workers' compensation benefits, the illness or injury must meet two specific criteria, which are the same as the case prior to COVID-19. First, it must arise out of the course and scope of employment, and, second, it must be caused by conditions that are specific to the work environment and duties of the worker. Because of the uncertainty of this disease and its pervasive nature of exposure and transmission in both public and employer-based work environments, it may be somewhat burdensome to associate the incidence of COVID-19 to the work environment with a compelling degree of certainty. Because of the higher risk of exposure in the health care environment, the burden of association may not be as challenging in the case of health care workers. It is currently not known yet what the number of COVID-19-related workers' compensation claims there may be. However, redeployment of workers' compensation and occupational health case managers in health care organizations to assume other duties has increasingly become a common reality. They have been sought out to proactively focus on workplace and workforce health and safety concerns because they are experts in addressing these challenges. Employers have relied 

• Assume responsibility, and partner with other providers and interdisciplinary care team members, for the assessment of staff for COVID-19 exposure, reassessment and decision-making about the need to place someone on quarantine or to return to work.

 Develop and implement screening and decision-making protocols. Differentiate nontest from test-based decision algorithms.  Be clear on categories of exposure risk; e.g., low risk (brief interaction or close contact with a COVID-19 patient wearing a face mask while the health care workers wearing full personal protective equipment), medium risk (prolonged interaction or close contact with a COVID-19 patient wearing a face mask while the health care worker's nose and mouth exposed), and high risk (prolonged interaction and close contact with a COVID-19 patient [or a family member at home who tested positive] who was not wearing a face mask and the health care worker was not wearing any personal protective equipment) (CDC, 2020a).

 Apply the CDC guidelines in the workers' compensation practice, as appropriate. Regularly monitor the CDC recommendations and update the practices, as necessary.

 Communicate COVID-19 screening, testing, monitoring, and return-to-work standards to the leaders and staff. Use a multimodality approach to communication; e.g., printed job aids, videos, formal memos, town hall meetings, and intranet sites.

 Be clear on the process of monitoring for symptoms, especially when placed off duty pending decision of return to work. Communicate monitoring expectations to health care workers and reporting on status of symptoms consistent with COVID-19 (i.e., fever, cough, and shortness of breath).

 Counsel staff about precaution measures at home, prevention of family members' exposure, or fear of exposure due to concerns that the work environment presents a higher risk for exposure; answer questions as necessary.

 Evaluate the need for early return to work of clinicians and other health care workers, especially in the case of staffing shortages. Communicate any required restrictions when in the work environment such as need to wear a mask all the time while at work. Apply the CDC recommendations in support of your practice decisions.

 Develop, implement, and communicate about workplace flexibilities and protections. Manage absenteeism and monitor its trends and patterns; proactively reach out to workers and address their fears and concerns. • Case manage the health care workers who are placed on leave based on workers' compensation benefits.

 Consider the implications of COVID-19 for health insurance coverage; be mindful of the need for timely access to services and return to work.  Collaborate with the medical/family leave unit or department if you have a separate team for such.  Maintain effective relationships with the workers' compensation liability and insurance carrier. Be proactive in establishing clear guidance on the financial implications of staff being out on extended leaves due to COVID-19 exposure-short-and long-term disability practices.

 Create a workers' compensation claim for worker placed on leave; review and confirm appropriateness of such claim and formally process as necessary.

 Investigate worker's exposure to COVID-19 and report to OSHA as necessary. • Develop and implement clear guidelines concerning health care workers (physicians, nurses, case managers, others) who may be excused from directly caring for suspected or confirmed COVID-19 patients. Examples of health conditions that may warrant exemption are immunocompromise status, pregnancy, or living with someone who is immunocompromised. In this regard, workers' compensation case managers may:

 Provide screening for health care workers who wish to be excused from caring for suspected or confirmed COVID-19 patients. Review the medical/health condition(s); discuss the associated risks; counsel about steps to mitigate the risk; and educate as about COVID-19 as necessary, including a review of monitoring for symptoms and effective use of personal protective equipment.

 Participate in the decisions made concerning health care workers reassignment or redeployment to other functions to ensure continued workplace safety.

 Be available for counseling of health care workers who are concerned about health conditions other than those identified for exemption or another serious condition they believe may put them at a significantly increased risk.

 Respect health care workers' privacy and confidentiality; adhere to applicable laws and regulations. • Establish and operate a COVID-19-specific center for workforce and workplace health and safety.

 Identify a physical location and hours of operations. Brand the center as the "COVID-19 workforce health and safety center."  Dedicate appropriate resources (personnel, supplies, technology, etc.) to the center; consider using clinicians identified for redeployment possibly due to low census in some care settings (e.g., ambulatory clinics) or cancellation of services (e.g., postponement of elective surgical procedures in the operating rooms and limiting interventional procedure areas to emergent cases).

 Equip the center with capability for collecting COVID-19 specimens for diagnostic testing such as nasopharyngeal swab collection kits.  Communicate location, purpose, services offered, and hours of operations to the workforce. Make sure that hours of operations are extended beyond the normal workday hours; the extended hours are especially important for staff who work off shifts.

 Offer on-site testing for exposure to COVID-2019.  Provide training for the clinicians involved in the center, especially for specimen collection and documentation of care provided. Remember, record keeping of these services may be required from a regulatory perspective, including the standards of the OSHA and other governmental agencies. • Consider launching a virtual call center for staff advice line, triage, counseling, and guidance.  Ensure the call center is accessible 24 hr per day, 7 days per week.  Use the call center for communicating the COVID-19 test results to the staff placed on leave (on quarantine at home) pending the results.  Provide phone-based screening of the staff members who are out with suspected COVID-19 regarding symptoms and guide them on returnto-work decisions.

 Answer staff's questions and link staff to services as appropriate.  Train the staff deployed to the call center on the expected responsibilities, workflows, escalation of concerns, required documentation, technology in use, and key operations or logistical activities. • Remind health care workers of the availability of the EAP team. Engage the team members in their potentially added roles and coordinate the services the team may provide to the health care workers.

 Offer psychosocial support and counseling, especially regarding COVID-19-related stressors (e.g., fear, anxiety, financial concerns), health, and well-being.

 Consider expanding the hours of operations of the EAP team; availability remotely off-hours.  Provide just-in-the-moment support and connection to care, including short-term counseling support, as needed and agreed upon by the health care worker.  Offer other services if possible: financial consultation, child and elder care support resources, legal advice, and well-being coaching.

(continues)

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on them to lead the development and implementation of COVID-19-related strategies, program offerings, and other activities aimed toward ensuring the health, safety, and well-being of employees (health care workers) and to reduce the risk of exposure to and transmission of the disease. Table 3 highlights important examples of such activities for workers' compensation case managers in the health care employer settings. It is likely for workers' compensation case managers to experience delays in the resolution of existing claims and the chance of future claims to remain pending for a longer time than usual. A primary contributing factor for these issues is the rise in current activities of addressing the COVID-19 pandemic and expectations of recovery from it. Other factors may be attributed to the closure of state workers' compensation offices, postponement of some claims, temporary discontinuation of field case management services, and limited availability of other resources including treating providers, vocational rehabilitation specialists, claims adjusters, diagnostic tests and procedures, and specialty interventions such as physical therapy and surgery. For these situations, workers' compensation case managers must continue to exercise diligence in supporting the workers who have suffered from a workrelated injury or illness in their recovery, keeping them informed through regular communications, providing psychosocial counseling and support, monitoring of (modifying as indicated) the return-to-work plan, and ensuring continuation of benefits as applicable. These efforts are of even greater significance because many of these workers will most likely either not have a job to return to or their employer may not approve a worker's need for modified duties or work hours.

a Brief perspeCtive on LegaL and ethiCaL Case management praCtiCe COVID-2019, like any other context of professional case management practice, requires requisite knowledge and skills about the standards of care and practice, ethical principles, and health care laws and regulations. It also requires the case manager's professional conduct. Case managers may encounter additional challenges because of the uncertain dynamics of this global pandemic that affect the timely delivery of care; for example, limited COVID-19 testing resources, constraints on long-term care providers, and surge in patient capacity in the acute care settings. These concerns contribute to an unusual increase in situations of moral distress and ethical dilemmas. Regardless, however, these circumstances still call upon case managers to apply evidence-based practices, exercise their ethical decision-making skills and compass, and seek the support of other experts in the same manner as handling any other ethical situation they may have encountered prior to the COVID-19 pandemic.

Case managers' accountabilities in the provision of health and human services to suspected or confirmed COVID-19 patients and their support systems are complex as a result of the pandemic nature of the disease that has affected virtually every health care setting across the continuum. It has contributed to an uncomfortable and uncontrollable separation between the patient and the patient's support system or designee caregiver as a result of "no visitation" policies in any health care setting (acute, ambulatory, and long-term) for fear of increased COVID-19 exposure and transmission. It has even impacted the safety of the home setting as a patient's discharge option in ways that are drastically different from the home safety issues usually encountered under normal and past transitions of care conditions. For example, the requirement of isolation (quarantine) while at home is a common need for the COVID-19 patients today compared with a rare necessity in the recent past. For some patients, the size and lay out of the home may not easily allow for safe patient quarantine and isolation precaution procedures. 

• Manage existing workers' compensation claims and ensure that the status of each claim is clearly documented.

 Communicate the status of the claim to the involved parties. Be transparent with the worker regarding the status of the claim and the reason for any delays in resolution or in care provision.

 Develop alternate plans of care to facilitate continued treatment and interventions. Shift to remote monitoring, if necessary.  Facilitate the continuation of workers' benefits.  Alert the worker who is "out on leave" that modified work option is not available due to the COVID-19 crisis. Offer concrete and alternate plans; avoid overpromising and stay realistic and practical.

 Review open claims regularly, especially those of high cost and value.  Adhere to the applicable laws, regulations, and employer policies and procedures. Follow the existing OSHA standards and those newly developed for the purpose of COVID-19. Respect the worker's preferences in communication and involvement of legal representative. Answer the worker's questions in a timely manner. Coordinate with the human resources and benefit department in a timely manner.

 Manage cost implications carefully; be aware that delays in return to work may result in increased expenses, reinstatement of benefits or extension of the coverage period, and/or loss of leverage in settling claims. This need has also contributed to concerns about whether the patient's support system is able to safely engage as the caregiver and for potential exposure to the disease. Other care options that have witnessed increased frequency are advanced care planning, palliative care, and end-of-life care, especially for the COVID-19 patients with a high severity of illness requiring hospitalization in an intensive care setting. At the center of these care situations are the professional case managers acting as the COVID-19 patient/support system advocates, the hub of care coordination, the center of transitions of care activities, and as integral members of the interdisciplinary health care teams accountable for addressing the care issues and ethical dilemmas encountered. In addition, case managers safeguard the interests of both their employer and the patient/support system they care for. They do this by adhering to the health care-related practice and legal standards and other applicable laws and regulations. These responsibilities may not be simple because of the dynamic nature of COVID-19, the constantly changing standards of care (i.e., CDC issued guidelines), and the regulatory flexibilities and waivers enacted by the CMS. Table 4 provides case management professionals with select guidance on how best to maintain current and effective practice, while observing ethical principles and values and adhering to legal requirements. Fundamentally speaking, professional case managers are expected to apply the case management standards of practice to any patient/support system under their care, including the suspected or confirmed  Complete a comprehensive assessment of the patient and the support system, including social determinants of health and comorbid health conditions (physical, emotional, mental, financial, and behavioral).

 Identify primary care needs and agree on desired care goals-patient/support system, health care team, and health insurance representative/ payer as appropriate.

 Apply the case management process in care planning, care coordination, and service delivery, the patient's transition to the next level of care, outcomes evaluation, and follow-up with the patient/support system post-transition from the encounter of care. Coordinate patient care services across providers and care settings.  Care for the person with an illness and not the illness of the person; provide person-centered care and wholistic case management service delivery; consider the person's whole situation, health and social circumstance, lifestyle, care goals and desires, and life experience. • Adhere to legal standards, laws, and regulations.  Consider the applicable regulatory standards in the planning and delivery of patient care and services: discharge planning, utilization management, value-based care.

 Respect the patient's bill of rights, Health Insurance Portability and Accountability Act (HIPAA), and Patient Self-determination Act.  Obtain informed consent and secure agreement of care goals by the patient/support system.  Be proactive in identifying potentially unsafe situations and risk mitigate accordingly. Complete comprehensive event reviews  Maintain open and authentic communication with the patient/support system and members of the interdisciplinary health care team.  Communicate with the health care team at the next level of care before the patient's transfer. Ensure next level of care can meet the patient care needs and required services.

 Document findings from patient evaluations, care interventions, responses, and outcomes; be factual.  Adhere to fraud and abuse laws and standards, especially in billing and claims processing.  Evaluate risk for litigation and malpractice concerns on an ongoing basis. For example, end-of-life care concerns, negligent practice, breach of confidentiality, and premature patient's discharge or transfer to the next level of care.

 Consult legal counsel when in doubt and seek advice as needed. • Apply ethical standards in practice.  Maintain the role of "patient/support system advocate" above all.  Follow common ethical principles in the provision of care to COVID-19 patients: autonomy, beneficence, nonmaleficence, veracity, justice, fidelity, and objectivity.

 Demonstrate common ethical values in the provision of care to COVID-19 patients: caring, compassion, honesty, transparency, authenticity, and empathy.

 Act in a culturally informed manner; be aware of unconscious bias; develop therapeutic relationships with the patients/support systems.  Pay special attention to end-of-life care concerns; facilitate advanced care planning and the provision of timely ethics and palliative care consults when needed; engage the patient's support system even if by using tele-case management approach and remote patient's visit with the patient's support system or designated caregiver.

 Promote peaceful and dignified death; connect the patient and the patient's support system during the dying period for expressions of goodbyes and emotional support; because of "no visitors" policy conditions, use interactive video and telecommunication technology to facilitate such visit.

 Exercise ethical decision-making and problem-solving while promoting shared and informed decision-making with the patient/support system and other members of the interdisciplinary health care team.

 Be mindful of ethical principles relevant to the use of social and digital media and health information technology. This is especially important when working remotely or virtually or using telehealth devices.  Demonstrate professional conduct; act responsibly and based on available codes of ethics of the case manager's professional background discipline (e.g., nursing, social work, pharmacy, vocational rehabilitation, therapy) and case management association/organization (e.g., Commission for Case Manager Certification).

COVID-19 patient. They also must refer to available evidence (scientific, expert opinion, and/or consensus statements) in the development of plans of care and provision of case management services. In these regards, they must remain abreast of the CDC and CMS guidelines that provide advice on how best to diagnose and manage patients with COVID-19 (CDC, 2020b) , including what criteria to consider in deciding whether to transition the patient to the home or long-term care setting (CMS, 2020b). These guidelines have also provided information about discharge planning (e.g., the patient's readiness for discharge from the acute care setting) and health instructions for engagement and self-care (e.g., transmission-based prevention practices while at home). Case managers may apply these COVID-19-specific guidelines in conjunction with the case management standards in their care provision practices and at the individual patient/support system level. Such approach to care coordination and transitions of care decisions ensures safe and quality care outcomes for the patient and the health care organization.

Although the ethical principles of case management practice are not any different in the COVID-19 crisis from other contexts of care provision or patient conditions, professional case managers must behave in ways that demonstrate continued adherence to these principles and values. They must also maintain interdisciplinary/interprofessional practice, provide patient/support system (person)-centered care, demonstrate the role of a patient advocate, apply evidencebased care interventions, and ensure timely access to services and resources including specialty care. In addition, case managers must treat their patients/ support systems with caring, compassion, professionalism, authenticity, transparency, empathy, and objectivity. It is through these behaviors that they can alleviate the patient's fear, anxiety, stress, and apprehension that may have emanated from the uncertain nature of the disease and its prognosis. Respecting the patient's bill of rights is one strategy that ensures the patient and the support system receive optimal care possible. It provides an obligation for information disclosure; autonomy as evident in the right to choose and communication of desired care goals, treatment plan, and transitions of care (disposition) including the next level of care; access to timely services; shared and informed decision-making; right to privacy and confidentiality; and opportunity for filing a grievance in the case of suboptimal care experience or other concerns.

Concerning the legal aspects of case management practice, health care laws and regulations (e.g., Medicare Conditions of Participation) remain a priority and expectation regardless of the COVID-19 pandemic. Not being clear about disease progression or confident whether the patient's home is a safe discharge disposition should not stand as barriers in designing the most effective and safe transitions of care plan for the patient/support system. Fortunately, the CMS has waived numerous regulatory requirements and enacted provisions that have contributed to smoother and more flexible discharge planning and utilization management procedures (details are available in Table 4 of Part I of this two-part article series; CMS, 2020a; Tahan, 2020). These also have created expanded opportunities for sites and modalities of care that ultimately have facilitated timely access to services despite the physical distancing and fear of exposure constraints imposed upon health care providers and the environment of care provision. Amidst such a regulatory environment of health care practice and COVID-19 crisis, professional case managers remain obliged to adhere to applicable laws and regulations and in support of effective resource allocation, coordination of services, and safe transitions of care for patients and their support systems, including those with suspected or confirmed COVID-19.

Other important standards case management professionals may apply in their practice as they care for patients/support systems with either COVID-19 infection or any other physical or mental health condition are those of the accreditation agencies such as The Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, and the National Committee on Quality Assurance. These standards provide guidance on multiple aspects of care delivery including the systems of quality and safe care provision, monitoring and reporting of outcomes, case management and interprofessional practice, patient's rights, and leadership.

Remote practice is neither new to the case management field nor to the health care industry at large. It refers to working from home or another alternate location that is different from the actual location of employment, that is, the address of the employer organization. Remote practice is a desirable option for fulfilling one's roles, responsibilities, and employment obligations in the case of a pandemic such as COVID-19, where physical distancing and limitations on gatherings and size of groups (e.g., the number interdisciplinary health care team members engaged in patient care management rounding) are imposed. It comprises the performance of one's role-specific duties and other authorized activities from the alternate location by using telecommunication (e.g., phone, interactive video), digital (e.g., e-mail, texting, online chat), and electronic technology (e.g., computer, mobile device) that operate through a connection to the World Wide Web, often linking the practitioner to the employer's own private network. Remote practice is also known by other terms including tele-work, tele-commuting, remote work, off-site work, virtual work, or virtual practice. Regardless of the term used, the contexts are alike. In health care organizations, remote practice denotes a work flexibility arrangement under which a health care professional such as a case manager practices from an approved worksite other than the traditional on-site work environment from which the professional would have otherwise practiced-performed one's work duties. It may entail a full-time, part-time, occasional, or transient remote practice arrangement. It also must enable the involved professionals to maintain contact with their colleagues, peers, supervisors, and customers (patients and their support systems). In addition, the remote practice setup must facilitate continuous access to materials (e.g., electronic health records) and other necessary resources for the professionals to effectively and efficiently execute their roles and responsibilities.

Remote or virtual practice in case management has been steadily increasing in popularity, especially in certain employment (care) settings where it is more feasible such as the health insurance plans and payer organizations. In these settings, the roles and responsibilities of the professional case managers (e.g., utilization review and beneficiary health counseling) do not depend on a face-to-face interaction in the same physical location between the case manager and the client (patient, enrollee, beneficiary), therefore, more conducive to working remotely. Often, these case managers are supported by using innovative mobile technologies that allow them to maintain ongoing connectivity with the formal office (the employer organization) no matter where they are. In contrast, the role and responsibilities of case managers in the acute care settings often require direct (face-to-face) contact with patients and their support systems. Although because of the COVID-19 pandemic, tele-case management services have become increasingly popular, especially when needing to connect with a patient's support system.

In the COVID-19 pandemic crisis, case management leaders and case managers have examined the appropriateness of alternate worksite options to prevent exposure to COVID-19 infection while ensuring the provision of safe and quality care to patients and their support systems. It is not foreign to see that a large percentage of case managers in the acute and other care settings shift their place of work to alternate venues including remote and telephonic environments. Most likely such changes have occurred without advance planning and formal preparation as it is usually the case in a time of disaster or crisis. Therefore, professional case managers and their immediate leaders must develop a degree of comfort in these models of care-expeditiously. It has been reported that even when physically present in the acute care setting, case managers have resorted to completing their patient/support system assessments and the development of case management and transitions of care plans telephonically or through video-calling • Seek clarity on the roles, responsibilities, and duties you are expected to perform remotely. Ask for an orientation or training regarding telework systems and processes even if brief.

 Gain familiarity with the specific roles and responsibilities, expected productivity measures, and related performance standards. Be clear about what is expected of you including documentation requirements.

 Learn the use of the required technology and digital tools.  Ask for the escalation and support procedures in case a problem arises or you face certain challenges and concerns.  Have contact information of key personnel (e.g., supervisor, health information technology help desk, and peers); telephone numbers and e-mails are necessary. • Arrange for a dedicated workspace at home (or the remote work location) and equipment. A dedicated workspace can help increase your motivation and provides you with the psychological expectation that when you are at the designated space, you are at work.

 Ensure the space is private, quiet, free of distractions, and conducive to productivity.  Designate a specific telephone line and computer.  Request to have interactive video communication capability. • Create and follow a daily work schedule and manageable routine; a time to begin and end the workday. These give your day some structure.

 Establish a similar workflow to what you would have done if you were practice on-site.  Check with your supervisor daily, once, twice, or as often as necessary.  Connect with a work colleague regularly for work updates, consultation on issues of concern, and peer support.  Schedule breaks. Taking breaks is an important part of managing your energy level.  Reduce distractions such as turning on TV and scrolling through newsfeeds on social media.  Use your peak energy hours effectively.

• Adhere to applicable privacy and confidentiality laws and regulations.  Ensure credible network security, encryption, and secure text messaging and video portals.  Do not leave any work-related confidential records open and accessible to other family members or housemates.  Respect the Health Insurance Portability and Accountability Act (HIPAA) and keep patients' personal health information confidential and secure. • Take time for self-care.  Commit to your fitness and exercise routine.  Eat healthy and nutritious meals.  Focus on being productive.  Know when to "log off" and disconnect. This can be one of the most challenging aspects for those new to remote practice.  Make time for your family members and friends (tele-case management) for many reasons, one of which to avoid exposure to COVID-19. Although they are considered "essential" practitioners, they may not be the fi rst professionals to enter the room of a suspected or confi rmed COVID-19 patient.

Case management leaders must identify the specifi c roles professional case managers are able to effectively perform remotely and establish ways to support these practitioners in their remote practice. The following is a list of functions most conducive to remote work of case managers. Table 5 also shares specifi c tips for effective remote practice.

• Perform utilization review and management activities such as payer notification of a patient's admission, preauthorization for services, and notification of transfers to another level of care. Submit clinical reviews as necessary based on the payer's procedures and expectations during the COVID-19 crisis. • Coordinate transitions of care plans and communicate patient transfers to another level of care. • Secure patient transportation, especially if an ambulance is needed. • Arrange for durable medical equipment such as wheelchair, bedside commode, shower chair, and oxygen therapy. • Follow up on consults expected of specialty care providers. • Complete medical/health record reviews for quality, safety, and outcome measures purposes. Identify and report unsafe care situations for proactive review by risk management and possibly for the conduct of detailed clinical event and peer reviews. • Conduct postdischarge and post-transitions of care calls to patients and their support systems to inquire about the patient's health and well-being. Perform a status check on COVID-19 symptoms, ability to adhere to precaution procedures (e.g., physical distancing, hand hygiene, use of face masks, and disinfection). Review understanding of health instructions and answer questions and as needed triage concerns and coordinate follow-up care.

The world and our daily lives have been unsettled across the globe because of COVID-19 ( Thorne, 2020 ) . This experience will certainly leave a lasting impact on all of us and our communities at large. Of note are our innovative responses and practices to the constantly changing care dynamics of those suffering from COVID-19. We will forever have a unique appreciation for the use of PPE-recognition for value and importance of adhering to the infection prevention standards-where their utilization will no longer be limited to health care settings, rather in usual consumption by the public and in societies as well. These departures from the norm have emphasized the signifi cance of public health practices and the importance of collaboration vertically and horizontally across health care organizations and providers and with other industries that support health care delivery systems. From a health care and case management perspective, the responses have been a deviation from the usual routines and comfort zones for many of our professionals, if not all. Constantly changing accountabilities for certain functions, fl exibility in priority setting, open mindedness to assuming responsibilities routinely not part of one's primary role, and ability to practice in environments of uncertainty and chaos have been the norm for virtually every health care professional including case managers since the rise of the COVID-19 pandemic. These have called for self-care and resilience more than ever before. Providing health care services during these uncertain times and constantly changing standards of care, workfl ows, and guidelines-often with no advance notices-presents many challenges requiring intentional self-care actions and a resilience frame of mind or state of being. These dynamics are undoubtedly a source of stress, anxiety, anger, frustration, and apprehension for everyone, including health care professionals and case managers who are at the front Concurrently, these times also are opportunities for each of the care team members to exercise one's higher purpose, refl ect on the reasons of having sought a health discipline as a profession, and demonstrate commitment to "serving others"-selfl essly.

Although showing up to care for others under increasingly complex and possibly compromised practice environment conditions (e.g., shortages of PPE) expresses professional and ethical obligation; it does not justify ignoring one's self-care needs or putting oneself on hold. After all, self-care and well-being are prerequisites to resilience and to providing safe care to the patients and their support systems whom we serve and to facilitate being fully available to and present with others.

lines of the COVID-19 crisis. Concurrently, these times also are opportunities for each of the care team members to exercise one's higher purpose, reflect on the reasons of having sought a health discipline as a profession, and demonstrate commitment to "serving others"-selflessly. Although showing up to care for others under increasingly complex and possibly compromised practice environment conditions (e.g., shortages of PPE) expresses professional and ethical obligation, it does not justify ignoring one's self-care needs or putting oneself on hold. After all, self-care and well-being are prerequisites to resilience and to providing safe care to the patients and their support systems whom we serve and to facilitate being fully available to and present with others. It is common for one to feel fearful of becoming infected with COVID-2019, regardless of whether a health care professional or a public member. However, as health care professionals and case managers, the nature of our daily practice presents a higher risk for exposure than other industries, which may contribute to experiencing additional types of fearfear for our families, elderly parents or grandparents, children, friends, professional colleagues, neighbors, and even our community at large-becoming carriers and/or a vehicle for the transmission of coronavirus to others. In these situations, it is important to acknowledge the feelings we may be experiencing and accept that the situation we are in "may not be fine." Under such circumstances, it helps if we move our focus away and rather to our case management roles and responsibilities instead. Focusing on the concrete and manageable allows us to feel productive and in control. Such is one step in managing our feelings and reactions. It also allows us to regain composure to then powerfully and deliberately address the real issues of concern we may be facing.

There are many schools of thought regarding self-care and coping during uncertain and challenging times (crisis). Regardless, psychologists and other experts may agree that there are common approaches, such as those listed in Table 6 , we may implement to

Self-Care Strategies and Resilience Skills for Case Managers in Times of Crisis • Take advantage of the services available to you through your employer such as employee assistance programs, behavioral health counseling services, and financial support. • Keeping your daily routine as normal as possible and pay special attention to your basic needs:  Eat nutritious meals and hydrate.  Exercise even if for a shorter time period than you are used to.  Practice your hobbies; e.g., reading, journaling, painting, watching a movie, gardening, or meditation.  Engage in social media as you have always done; remember to be careful regarding privacy and confidentiality rules and regulations.  Maintain contact with friends and families.

• Exercise emotional intelligence:  Maintain a heightened awareness of your own emotions and those of others.  Acknowledge ineffective behavior and apologize, as necessary.  Slow down and avoid reacting.  Pause and discuss your concerns with others as necessary; be available to listen to the concerns of others around you when asked.  Demonstrate a supportive care team member attitude; express caring and compassion.

• Practice mental personal protection and resilience:  Seek the support of others including peers, family and friends, counselors, and other persons.  Sleep enough hours to rejuvenate and be ready for the next workday.  Take short and frequent breaks throughout the day/shift; few minutes to reflect and regain composure as needed.  Express your feelings and share your emotions with others, especially your peers at work.  Allow yourself to feel grief and sadness; it is normal; seek support as necessary, especially when these feelings become overwhelming to manage.

 Use any relaxation strategy you are accustomed to daily such as meditation or listening to music.  Take a day off or a break from direct care provision; request a work shift of administrative duties or work remotely for a day, if possible. • Talk about something other than COVID-19 with others whether in person or via digital communication technology. • When experiencing fear, anger, anxiety, frustration, or feeling overwhelmed, be intentional and shift to managing the things you can control and seek the support of others for those you cannot. • Seek grief counseling and the assistance of "care of the caregiver" support teams. This is helpful when you experience a higher number of patient deaths than usual such as the case with COVID-19, upon the death of a colleague, or feeling sad because of "no family present" with a patient at the time of death. • Be mindful of the dynamics of your practice environment and other members of the care team. These are an excellent clue for your desired behavior.

 Accept the reality that "we are constantly adjusting" to new information and requirements.  Be intentional; express acts of kindness toward others and accept those presented to you.  Stay alert of isolating behaviors; it is rather natural to keep to yourself in times of sadness and concern. However, these are the times when you should shift the isolating behavior and purposefully seek the support of others.

 Notice the isolating behaviors your care team members are demonstrating; offer your support to them during these times. • Verbalize your needs to your leader(s):

 Ask for training on new responsibilities you may have been asked to assume during the crisis, when applicable and especially if you lack competency in. It is acceptable to receive training on activities you are uncomfortable performing.

 Express your needs and request support.  Ask questions; inquire about the uncertainties you are experiencing.  Offer to take charge of activities you are excellent at.

regain comfort, confi dence, and control over our anxieties and apprehensions in rather uncertain times. These may focus on impactful coping strategies during a crisis and self-care activities to reenergize and recharge ourselves. They also potentially facilitate feeling resilient, emotionally empowered, and actively engaged in both the social and practice (work) environments, including the health care teams we belong to. The recommendations are not comprehensive; what is most important, though, is to practice what feels feasible and impactful and to ask for support, as needed. No one is masterful at every aspect of life and help is available; one needs to reach out and ask for it. It is necessary to focus on staying emotionally, mentally, and psychologically resilient. Both case management and health care leaders are as responsible as the case managers and other professionals for ensuring that the environment of practice and patient care delivery is conducive to everyone feeling safe, secure, clear, in control, empowered, engaged, comfortable, and resilient. Health care professionals are indispensable to the care of patients and their support systems. Therefore, leaders must demonstrate their accountability for ensuring that professionals, including case managers, remain emotionally, mentally, psychologically, and physically resilient-fully available and present to provide safe and quality care. They also should remove stress, uncertainty, and anxiety to the degree feasible to enhance the resilience and well-being of the health care team members. They may simply achieve this through ongoing communication and transparency about the COVID-19 crisis. They also must demonstrate impactful crisis management and resilience skills. Table 7 recommends essential actions and strategies for leaders to support the self-care and resilience of their teams.

Case management program leaders may also apply the recommendations presented in Table 6 to take care of themselves-Leaders are human too and need self-care and resilience in times of crisis as well. It is common that leaders (case management leaders) may feel exhausted and may gravitate toward isolation. During these times, it is highly important to seek It is common that leaders (case management leaders) may feel exhausted and may gravitate toward isolation. During these times, it is highly important to seek the support of others (e.g., a colleague, friend, family member, supervisor, or mentor), especially with whom you feel comfortable refl ecting on the crisis, sharing your feelings, or asking for advice.

Case Management Leaders Behaviors That Promote Self-Care for Team Members in Times of COVID-19 Crisis the support of others (e.g., a colleague, friend, family member, supervisor, or mentor), especially with whom you feel comfortable refl ecting on the crisis, sharing your feelings, or asking for advice. The interprofessional care team members may feel grief and compassion fatigue because of the increased number of COVID-19-related deaths; in some instances, a care team fellow member may become acutely ill and die from exposure to the disease. Leaders in these situations may facilitate grief counseling, provide care for the caregiver, and coordinate support services for their team members and for themselves. It is important to recognize and acknowledge these feelings; create special time and space for grief and sadness; express kindness; be empathetic; and offer help and support in any way, even if small.

Crises such as the current COVID-19 global pandemic challenge everyone personally and professionally and prompt us to think innovatively. They also are catalysts for renewal and continued advancement because of their disruptive nature, questioning the status quo, and forcing instant creativity. Often after a crisis is over, some if not all the new and different strategies that have been applied to counter the effect of the crisis become common practice. These imposed real-life and real-time experiments allow for necessary growth and progress to occur-naturally. During these times of complex change, leaders and their team members (case management leaders and professional case managers) must stand tall, display character and skill, be adaptable to changing situations, be mindful of own actions and those expressed by and toward others (behaviors and emotions), maintain visibility, nurture trust, offer support, acknowledge the optimal behaviors displayed by others, and express gratitude. These qualities are not as simple to maintain-constantly, every time. In contrast, it is undoubtedly easier to adopt a new standard of care or a change in a practice guideline. Therefore, innovation in the development and execution of action plans to address a crisis such as COVID-19 requires the "character of an infl uencer" from those involved, leaders and subordinates alike, for long-term success-one that inspires a belief that everyone will come together and face the crisis head-on. And one that instills calm, confi dence, trust, transparency, and open dialogue, not only in words but in concrete actions as well.

Although the COVID-19 global pandemic has consumed every health care professional, whether a leader or a practitioner, and professional case managers are no exception, it has been a time for innovation and "expansive mind-set." It has brought about new models and methods of care delivery and created opportunities for collaboration across various industries and health care organizations and providers in ways never thought possible before. These undoubtedly will change case management practice for many years to come. The rise of new and nontraditional sites of care and the use of digital interactive and communication technologies will continue to make a popular site of care. It will also support the persons' engagement in their own health and well-being while advancing adherence to health regimens and follow-up care. Use of tele-case management services is not any different. Newly tried modalities of care will remain necessary and valuable to quality, safety, and fi nancial outcomes. For example, tele-rounding by the interprofessional health care team members for patient care management has resolved the concerns of some essential members being unable to participate because they cannot be available in person. Another example is the use of tele-consults for specialty care providers, allowing a timely completion of such service and preventing delays in care progression. A third example that is most relevant to professional case managers is remote/virtual practice, which during the COVID-19 crisis has been proven to work as well for the acute care setting as it has worked for the payerbased organizations.

Innovative care provision approaches have arisen during the COVID-19 crisis from the practice environments and the direct input of a diverse workforce, including professional case managers and leaders.

Often after a crisis is over, some if not all the new and different strategies that have been applied to counter the effect of the crisis become common practice. These imposed real-life and real-time experiments allow for necessary growth and progress to occur-naturally. During these times of complex change, leaders and their team members (case management leaders and professional case managers) must stand tall, display character and skill, be adaptable to changing situations, be mindful of own actions and those expressed by and toward others (behaviors and emotions), maintain visibility, nurture trust, offer support, acknowledge the optimal behaviors displayed by others, and express gratitude.

These have not been applied on the basis of guidelines written in textbooks or policy manuals; rather, they constitute a set of practice-based evidence developments. They also have been created and revised multiple times ever since and most likely will continue to undergo further adjustments because we are continuously learning new things about the virus and the infection. Furthermore, these creations have been designed in real time and based on reflection in action approaches. Therefore, to scale up the utility of these innovations, we must write about the effectiveness of such creations and disseminate them to the case management community at large for broader adoption and normalization into case management programs and practices. This two-part article series has presented select strategies from case management practices during the COVID-19 epidemic. These focused on what the author considered essential and worthy of sharing, although there may have been numerous other examples of successful and impactful care delivery approaches, ones that have continued to advocate for patients and their support systems, provided caring and compassionate patient-focused services, and facilitated timely access to health care resources despite all the odds. These articles also emphasized the importance of ensuring legal, ethical, and evidencebased practices while responding to unprecedented challenges. In addition, they identified the need for self-care and resilience, which are even most essential to maintain sanity during times of crisis and chaos. Despite being consumed in the myriads of priorities and concerns of the COVID-19 crisis, it is as important to focus on the future, what is next, and what is beyond the current crisis. Impactful leaders are adaptive and skilled in anticipating what is needed for long-term success. The time is now for case management leaders to make sense of the current experiences of the crisis, reflect on what made the action plans effective, and begin to identify how the new environment of case management should be like. They must be (or prepare to be) actively engaged in the "what is next" and recovery conversation at their organizations. They also must seek the feedback and input of professional case managers who have been directly involved at the front lines of care delivery. Together, they can understand how best to function in an environment that is fraught with uncertainty and build on what would otherwise have been unrealistic partnerships and collaborations to continue to advance and be future oriented in their pursuits. The future is now! aCknoWLedgments The author expresses his gratitude for all the case managers and other health care professionals directly or indirectly involved in caring for those who suffered from COVID-19. The author thanks them for being everyone's hero in this crisis. Their selflessness and commitment to their higher purpose of "serving others" are inspiring.

• Demonstrate special attention to the health, safety, and well-being of the health care team members, including case managers. • Communicate, communicate, communicate-Ensure authenticity, transparency, timeliness, repetition, and communicate continuously. Frequent updates using multiple modes of communication and sharing the organization's plan of action reassure the care teams

• Maintain visibility with the team and observe for signs of burnout, confusion, fear, sadness, and concern

Act in a caring and compassionate manner; spend appropriate time listening to your care team members; be tolerant and express empathy and understanding; avoid erratic behaviors, outbursts, and expression of frustration

Accept the fact that you may not have the answer for every question; exercise vulnerability and admit what you do not know

Inform care team members of the support services made available to them (already existing and newly secured because of the COVID-19 crisis)

facilitate team members' access to these services when needed

• Express gratitude; recognize and acknowledge the care team's efforts to maintain the delivery of safe and quality care to patients and their support systems and/or those evident of continued collaboration and teamwork

COVID-19 crisis is a stressful time for all whether due to uncertainty, patient surge capacity, fear of exposure, or burnout due to increased workloads and patient acuity

• Create predictability and stability to the degree possible; facilitate a sense of normalcy through usual workflows and routines, if possible. For example, establish routine times for huddles and communications

Be mindful of care team members' compassion fatigue; express empathy in these situations and offer support. The acuity of COVID-19-positive patients' conditions and number of deaths has increased clinicians' vulnerability to experience compassion fatigue

• Maintain staff engagement and retention activities as a priority during the crisis. In fact, the risk of staff turnover due to the crisis is most likely heightened because of the uncertain and challenging dynamics of the practice environment. Remember the newly hired staff as well; onboarding and orientation shortcomings may

Guidance for infection control and prevention concerning coronavirus disease (COVID-19): FAQs and considerations for patient triage, placement and hospital discharge

Essential case management practices amidst the novel coronavirus disease 2019 (COVID-19) crisis, Part I: Tele-case management, surge capacity, discharge planning, and transitions of care

Nursing in uncertain times

is a case management consultant, expert, author, and researcher