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2016 Standards of Practice for Case Management: The Expanding Role of the Professional Case Manager

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Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

I recently found a detailed paper entitled, Case Management: What It Is and How It Can Best Be Implemented, written in 2011, that describes case management in the National Health System (NHS) in the United Kingdom (U.K.). One of the key recommendations was to implement well-targeted, effective, collaborative, community-oriented case management programs to meet the complex needs of patients with long-term conditions, as part of a wider strategy for integrated care. The paper was an interesting and thorough overview of case management in the U.K. It demonstrated that even though we have very different healthcare systems, we have similar processes, opportunities and challenges. I would highly recommend reading this, if you get a chance.

The article was particularly interesting to me, since I worked on a consulting project in Northern England about 15 years ago to see if and how U.S. case management (CM) processes could be implemented in the National Health System (NHS) to facilitate, coordinate, and prioritize care. The goals of our project were to identify ways to improve the timeliness of care throughout the system, identify potential alternate levels of care that could be developed and used to free up inpatient beds, assure patient and provider satisfaction with the new changes, and improve outcomes. Care management processes and evidence-based guidelines were customized to assure they would work in the U.K. system. The project was very successful and a great learning experience for me, as I got an inside look at the NHS and how it compared with our healthcare system.

Although they were behind the U.S. in terms of implementing case management, it did tend to grow. In 2001, the Case Management Society UK (CMSUK) was formed, with help from CMSA, and in 2005 CMSUK developed Case Management Standards and Best Practice Guidelines, similar to our Standards of Practice for Case Management. It is reassuring to know that CM has been successful in the U.K. and that CMSA was associated with that.

Speaking of standards of practice, I am sure you are aware that the CMSA Standards of Practice, first developed in 1995, were recently updated in 2016. This is the third update, with previous updates being completed in 2002 and 2010. These Standards identify and address important foundational knowledge, skills, competencies, and other key factors that professional case managers (CMs) need to address in their practices. They include a spectrum of CM practice settings, specialties, and health and human service disciplines. The 2016 update was done to emphasize the professional nature of the practice and role of CMs and to legitimize the evolving role of professional case management as an integral and necessary component of the healthcare delivery system in the U.S. Kathy Fraser, Executive Director of CMSA, said these updates "reflect the expanding role of the professional case manager and help define the value case managers bring to the changing healthcare system, as critical members of the collaborative care team and crucial contributors in assisting the care team to achieve positive outcomes."

The 2016 Standards reflect changes in the industry since 2010 and important factors that CMs address in their day-to-day practice:

·Minimizing fragmentation in the healthcare system, application of evidence-based guidelines to promote collaborative care coordination, navigating transitions of care, and incorporating adherence guidelines and other standardized practice tools.

·Expanding and maximizing the contribution of the collaborative healthcare team to plan care and services, improving the experience for patients and their families, and ensuring safe, quality and cost-effective outcomes,

The changes to the 2016 Standards include:

General Updates:
  • The term professional has been added throughout the Standards when describing case management or a case manager
  • Reflects legal and regulatory changes affecting profession of case management
  • Recognizes research and practice innovations to the advancement of professional CM
  • Reduces use of stigmatizing language, e.g., problems/issues and termination; these were changes to care needs/opportunities and closure
  • Changes to citations, references, and additional resources
Specific Updates (underlining denotes a change to the definition):
  • Definition of Case Management: "a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes."

The Standards include new titles and information:

  •  Standard A Definition Changed:

             o The professional CM should screen clients referred for CM services to identify those who are appropriate for and most likely to benefit from CM services available within a particular practice setting.

  •  Standard B Definition Changed:

             o The professional CM should complete a thorough individualized client-centered assessment that takes into account the unique cultural and linguistic needs of that client including client’s family or family caregiver, as appropriate.

  • Standard C Title changed to Care Needs and Opportunities Identification.

             o Definition Changed: The professional CM should identify the client’s care needs or opportunities that would benefit from CM interventions.

              -Removed stigmatized wording; eliminated problems/issues

  •  Standard D Definition Changed:

             o The professional CM, in collaboration with the client, client’s family or family caregiver, and other members of the interprofessional healthcare team, where appropriate, should identify relevant care goals and interventions to manage the client’s identified care needs and opportunities. The CM should also document these in an individualized CM plan of care.

  • Standard E Definition Changed:

             o The professional CM should employ ongoing assessment with appropriate documentation to measure the client’s response to the CM plan of care.

  •  Standard F Definition Changed:

             o The professional CM, through a thorough individualized client-centered assessment, should maximize the client’s health, wellness, safety, physical functioning, adaptation, health knowledge, coping with chronic illness, engagement, and self-management abilities.

  • Standard G Title changed to Closure of Professional Case Management Services

             o Standard G Definition Changed: The professional CM should appropriately complete closure of professional CM services based upon established case closure guidelines. The extent of applying these guidelines may differ in various CM practice and/or care settings.

             o Reduces stigmatized words, e.g. termination; changed to closure

             o Recognizes potential misunderstanding of termination meaning that health coverage is ending

  • Standard H Definition Changed:

             o The professional CM should facilitate coordination, communication, and collaboration with the client, client’s family or family caregiver, involved members of the interprofessional healthcare team, and other stakeholders, in order to achieve target goals and maximize positive client care outcomes.

  •  Standard I Definition Changed:

             o The professional CM should maintain competence in her/his area(s) of practice by having one of the following:

             o  Current, active and unrestricted licensure or certification in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline; or

             o  In the case of an individual who practices in a state that does not require licensure or certification, the individual must have a baccalaureate or graduate degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of the persons being served. The degree must be from an institution that is fully accredited by a nationally recognized educational accreditation organization, and; and the individual must have completed a supervised field experience in CM, health or behavioral health as part of the degree requirements.

* Clarifies the state in which a CM practices as a driver of qualifications when an individual practices in a state that does not require licensure or certification

  •  Standard J Definition Changed:

             o The professional CM shall adhere to all applicable federal, state, and local laws and regulations, which have full force and effect of law, governing all aspects of CM practice including, but not limited to, client privacy and confidentiality rights. It is the responsibility of the professional CM to work within the scope of his/her license and/ or underlying profession

Note:In the event that the professional CM’s employer policies or those of other entities are in conflict with applicable legal requirements, the CM should understand that the law prevails. In these situations, CMs should seek clarification of questions or concerns from an appropriate and reliable expert resource, such as a legal counsel, compliance officer, or an appropriate government agency.

           - Clarifies precedent in situations where organizational policy conflicts with legal requirements

             o Additional Language for two sub-standards:

                 -Confidentiality and Client Privacy

                       *The professional CM should adhere to federal, state, and local laws, as well as policies and procedures, governing client privacy and confidentiality, and should act in a manner consistent with the client’s best interest in all aspects of communication and recordkeeping whether through traditional paper records and/or electronic health records (EHR).

Note: Federal law preempts (supersedes) state and local law and provides a minimum mandatory national standard; states may enlarge client rights, but not reduce them. For those who work exclusively on federal enclaves or on tribal lands, any issues of concern should direct them to the licensing authority and/or federal law.

             o Consent for CM Services

                 *The professional CM should obtain appropriate and informed consent before the implementation of CM services.

  •  Standard K Definition Changed:

             o  The professional CM should behave and practice ethically, and adhere to the tenets of the code of ethics that underlie her/his professional credentials (e.g., nursing, social work, and rehabilitation counseling).

  •  Standard L Definition Changed:

             o  The professional CM should advocate for the client, client’s family or family caregiver, at the service delivery, benefits administration, and policy-making levels. The CM is uniquely positioned as an expert in care coordination and advocacy for health policy change to improve access to quality, safe, and cost-effective services

                   -Enhances language to include client’s family or caregiver

                   -Stresses CMs unique role in care coordination and advocacy

  •  Standard M Definition Changed:

             o  The professional CM should maintain awareness of and be responsive to cultural and linguistic diversity of the demographics of her/ his work setting and to the specific client and/or caregiver needs

             - Emphasizes linguistic diversity of one’s work setting and attention to caregiver needs

  •  Standard N Definition Changed:

     o The professional CM should integrate factors related to quality, safety, access, and cost-effectiveness in assessing, planning, implementing, monitoring, and evaluating health resources for client care

  •  Standard O Definition Changed:

            o The professional CM should engage in scholarly activities and maintain familiarity with current knowledge, competencies, CM-related research, and evidence supported care innovations. The professional CM should also identify best practices in CM and health care service delivery, and apply such in transforming practice, as appropriate

- Recognizes professional growth takes many paths
- Research and research utilization continue as essential elements of professionalism
- Emphasizes practice advancement through application of systematic and documented process improvement
- Recognizes a wider scope of professional responsibilities and scholarship in every day practice across the entire care continuum

Every case manager should be familiar with the Standards of Practice. They are voluntary practice guidelines that define the rules for competent care, e.g. defining functions, roles, responsibilities, performance measures, procedures, actions, processes, knowledge requirements, and skill sets. Standards are used as the basis for: quality improvement initiatives, certification and credentialing, nurse training and educational programs, job descriptions and performance appraisals, and operational functions. These dynamic and ever-evolving Standards are an integral component of case management practice and essential for establishing and maintaining high quality practice and delivery of care. The American Nurses Association (ANA) describes standards as the "who, what, where, when, why and how of nursing practice".


The Standards don’t stand alone. They are built upon Guiding Principles, which are relevant and meaningful concepts that clarify and guide practice. These include fundamental rules, norms, or values that describe what is desirable. They tend to be more general, apply to all aspects of practice regardless of the setting, and form the foundation for the Standards of Practice. The Guiding Principles of case management practice are:

  • Use a client-centric, collaborative partnership approach
  • Whenever possible, facilitate self-determination and self-care through the tenets of advocacy, shared decision-making, and education
  • Use a comprehensive, holistic approach
  • Practice cultural competence, with awareness and respect for diversity
  • Promote the use of evidence-based care, as available
  • Promote optimal client safety
  • Promote the integration of behavioral change science and principles
  • Link with community resource
  • Assist with navigating the health care system to achieve successful care, for example during transitions
  • Pursue professional excellence and maintain competence in practice
  • Promote quality outcomes and measurement of those outcomes
  • Support and maintain compliance with federal, state, local, organizational, and certification rules and regulations

Because the Standards of Practice are such an integral part of case management, CMSA chose them as the first topic for its initial Career and Knowledge Pathways program, CMSA Standards of Practice: The Foundation for Professional Excellence in Coordination of Care Across the Continuum. It is designed for organizations to use in orienting new case managers or for individual case managers who want to increase their knowledge in the practice.

The Standards of Practice for Case Management are a "must read" for all case managers. So be sure to find some time to review the 2016 Standards and as you do, take time to reflect on the overall high level of commitment, performance expectations, and care delivery they describe. Then take some time to congratulate yourself on the profession you have chosen – one dedicated to excellence and caring.

Pat Stricker, RN, MEd, is senior vice president of Clinical Services at TCS Healthcare Technologies. She can be reached at pstricker@tcshealthcare.com.

 

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