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Case Managers Respond to National Survey
The first annual American Health Consultants (AHC)/Case Management Society of America Case Management Caseload Survey was distributed in the December 2000 issues of seven AHC newsletters, including Case Management Advisor. In addition, the survey tool was available on-line at www.ahcpub.com and www.cmsa.org through mid-January 2001. A total of 522 case managers representing a wide range of practice settings responded on-line or by fax. The largest response rate came from acute-care case managers, who accounted for 36.5% of the total respondents. Other case managers represented in the data set include:
An executive summary of the entire data set has been on-line at www.ahcpub.com and www.cmsa.org since late March. In addition, Case Management Caseload Data: Results of a National Survey, a white paper analyzing the data set by practice setting, is available for $49 from AHC. For ordering information, call customer service at (800) 688-2421.
Six years full of rapid changes in the health care delivery system have passed since the Case Management Society of America (CMSA) in Little Rock, AR, introduced the Case Management Standards of Practice in 1995. Six years ago, case managers weren’t monitoring chronic illness via the Internet. Six years ago, many hospital case managers were busy with discharge planning or utilization management in facilities that didn’t have a case management department. And six years ago, the CMSA Standards of Practice Committee identified six core components of the case management process that, even today, some case managers simply ignore.
The six core components first identified and defined in 1995 are: assessment, planning, implementation, coordination, monitoring, and evaluation. Industry insiders almost universally agree that the time an individual case manager spends on each of these functions varies by practice setting and even by the type of case. But coming as a surprising twist to many of the professionals interviewed by Case Management Advisor, the 2000 American Health Consultants/CMSA Case Management Caseload Survey reveals that some case managers are completely leaving out one or more core components of the process.
Specific findings include:
• Roughly 3% of case managers reported spending none of their time on assessment.
• Nearly 4% reported spending none of their time on planning.
• Nearly 5% reported spending none of their time on implementing.
• Roughly 4% reported spending none of their time on coordinating.
• Roughly 6% reported spending none of their time on monitoring.
• More than 7% of case managers reported spending none of their time on evaluation.
The question then becomes: If a case manager leaves out one or more of the six core components of the case management process, is it still case management? Many experts say that it’s not.
"It amazes me," says Carrie Engen Marion, RN, BSN, CCM, president of Advocare/Triage in Naperville, IL, "that 3% of case managers spend no time on assessment whatsoever. The core components of the case management process are the foundation of the field of case management. They are absolutely essential, and there is not one of them that can be left out in any case management program, practice setting, and/or discipline. If case managers are not spending any time on one or more of these core process components, then they are doing something besides case management."
Anne Llewellyn, RN-C, BPSHA, CCM, CRRN, CEAC, owner and independent case manager with Professional Resources in Management Education in Miramar, FL, prefers the word "crucial" to "essential," but the sentiment remains unchanged. "How can you manage a case if you don’t do an assessment? How can a patient progress if there is no plan? How is the case kept on track if no one monitors it? How do we know we are doing a good job if we never evaluate?" she asks. "These are simple and crucial functions of case management. I am distressed to see the stats [from the Case Management Caseload Survey] because I think they indicate that the people who answered the survey don’t understand the practice of case management as very simply stated in the CMSA Standards of Practice."
No matter how much the industry changes, the process is static, she argues. "Case management is a fluid practice, but the basics don’t change."
"How can one best meet the needs of a client without determining the client’s needs?" asks Peter Moran, BSN, MS, RN, Cm, CCM, nurse case manager with Harvard Pilgrim Health Care in Wellesley, MA. "I believe this is an example of so many professionals calling themselves case managers when they are actually performing utilization review or discharge planning. Case management requires all the steps in the process to occur."
Although each of the six steps of the case management process should be applied to every case a case manager works, the time spent on each step will vary, experts say. The demands of each patient and his or her family, as well as the diagnosis and other circumstances dictate how much time the case manager devotes to each step.
"It is not acceptable to leave out any steps in the process," notes Jacqueline J. Birmingham, BSN, MS, RN, CMAC, executive director of Continuum Care Services in Suffield, CT, "but it is acceptable to move back and forth. Case management is a dynamic process, meaning that there is movement across all the steps at a variety of pace and intensity. Time devoted to each step depends on what the client/patient needs or what resources are available or changing."
Each case brings new challenges, Moran adds. "In some situations, the assessment is clear-cut, but a great deal more time must be spent on planning and implementation due to issues such as lack of payment source, lack of social support systems to assist in the post-discharge phase, or problems with adherence," he explains. "Still other times, you may find a client who continues to fail at home for unknown reasons, and the assessment and evaluation phases then become prolonged until a workable plan is defined and implemented."
Similarly, just as it’s natural for the time spent on each step of the case management process to vary from case to case, it’s also natural to see variance by practice setting, experts agree. Practice setting analysis of the 2000 Case Management Caseload Survey reveals the following practice setting variances:
• 34% of acute-care case managers reported spending between 16% and 30% of their time "planning," compared to 40% of health plan case managers and 52% of independent case managers.
• 34% of acute-care case managers reported spending between 16% and 30% of their time "coordinating," compared to 44% of health plan case managers and 54% of case managers working in skilled-nursing or rehabilitation facilities.
• 17% of acute-care case managers reported spending between 16% and 30% of their time "evaluating," compared to 25% of skilled-nursing or rehabilitation facility case managers and 34% of independent case managers.
"It’s to be expected that the distribution of time for each step of the case management process varies by practice," says Birmingham. "Not all practice settings pose the same challenges. That’s why the case management process is so alive and well — it guides case management in whatever setting the case management happens."
Many factors determine the time devoted to each of the six components of the case management process, explains Jeanne Boling, MSN, CRRN, CDMS, CCM, executive director of CMSA. "This is where the information system resource available to the case manager and the individual case manager’s judgment and experience become crucial. What time is spent is a professional judgment. When the CMSA Standards of Practice were written, they were never meant to dictate an even distribution of time and effort be spent on each of the six components of the process."
Further, rapid changes in the industry have led a push for updated Standards of Practice. "The process of case management is critical and cannot be changed," says Boling. "However, it may be important to look at whether each individual case manager must perform each function in the process, or whether working together in teams, if many can share the process without disintegrating the outcomes. As we learn more about the various ways in which various health systems implement case management successfully, it will be important to update the CMSA Standards of Practice."
Moran agrees that it may be possible to apply a team approach to the standards. "It may be that in certain systems different people do individual steps in the total process," he notes. "However, for the process to work, all six steps must be addressed."
Yet another example may be case managers working in concert with other professionals outside their own organization, Llewellyn suggests. "If you, as an independent or payer case manager, are working with a very strong discharge planner in the hospital who takes responsibility for implementing the plan of care in total, you would need to follow through to make sure that everything was done and everyone knew what was the plan, and all reimbursement issues were in place, but you may not have to do the actual work of implementing the plan yourself."
Case managers should retain oversight on all their cases, urges Sandra L. Lowery, RN, BSN, CRRN, CCM, president of CCMI Associates, an independent case management company in Francestown, NH, and immediate past national president of the CMSA. "While a case manager can utilize and access others to assist them in the process, the very essence of case management disallows delegation of the core functions," she stresses. "To be more specific, a case manager can request that an assistant gather medical records, locate resources, and send records from one party to another to promote coordinated care. However, the interviewing skills of the case manager are necessary to obtain a comprehensive assessment, and the communication skills of the case manager to advocate for a change in treatment plan are such that these functions cannot be delegated. Moreover, as the relationship with the client is essential and foremost per the standards of practice, this relationship cannot be delegated to others."
Still, practice standards must keep pace with the industry they serve, notes Lowery. "CMSA’s Standards of Practice for Case Management are considered a dynamic document and, as such, are subject to revision as the practice of case management evolves," she says. "Published in 1995, the standards are due for review and updating. Much has changed since their initial development, and these changes may indicate a need for revision."
CMSA continually has solicited feedback from its more than 7,000 members regarding the standards. "Specific feedback to date has related to the application of the standards with the request that they provide more guidance for actual application of the case management process," says Lowery. "Other issues that may be addressed are the standard that case managers have a minimum of a baccalaureate degree. The standard for advocacy for policy changes has raised questions as well."
CMSA has formed a multidisciplinary national task force to lead an effort to review and update the standards this year. "We felt that, after five years, a concerted effort to solicit feedback and incorporate it into an updated document was needed," explains Lowery.