ISSUEBRIEF. CONVERGING PATHWAYS A Journey Towards Quality Case Management

Transcription

1 ISSUEBRIEF VOLUME 1, ISSUE CONVERGING PATHWAYS A Journey Towards Quality Case Management Development of case management as a profession surged in the latter part of the last century, due in large part to the birth in 1990 of two quality-focused organizations. In that year, URAC was established to improve the quality and accountability of organizations conducting utilization review, but in later years expanded to accreditation of organizations conducting many medical management components such as case management and disease management. Today the organization has 17 accreditation programs. In that same year, the Case Management Society of America (CMSA) was established to support and develop the profession of case management through educational forums, networking opportunities and legislative involvement. Today the organization has about 9,000 members. In the arena of case management, URAC and CMSA have traveled tandem and often converging paths. As CMSA developed educational tools and quality standards for individual case managers, URAC developed quality standards and an accreditation program offered to organizations providing case management services. Individual professional case managers can be expertly prepared, but if they re working in an organization that is not committed to case management quality, they will not be able to achieve the outcomes they are capable of, said Jeanne Boling, MSN, CRRN, CDMS, CCM, executive director of CMSA and member of URAC s board of directors. URAC accreditation serves that critical function of establishing the organization s policies, procedures and structure needed for optimal case management performance. A century of case management In the early 1900s, public health nurses and social workers began to coordinate care for patients with complicated health needs, and case management was born. Following World War II, the U.S. government employed a variety of practitioners to aid soldiers who had suffered complex injuries. Soon after, insurance companies began to employ nurses, social workers, and vocational rehabilitation counselors to assist with coordinating care for others requiring individualized care plans with multidisciplinary intervention. 1 By the 1970s, Medicare and Medicaid employed case management in demonstration projects and in community programs for the mental health and developmentally delayed populations. In the private sector, workers compensation insurers initiated case management services, and a small group of private rehabilitation firms emerged to provide medical management and Individual professional case managers can be expertly prepared, but if they re working in an organization that is not committed to case management quality, they will not be able to achieve the outcomes they are capable of. vocational placement services to injured workers under states workers compensation systems. The purpose of both privately and publicly delivered case management services was the same: to coordinate, facilitate and monitor over time a client s use of an array of health and social services. 2

2 ISSUEBRIEF2 In the 1990s, case management emerged as a health care discipline of its own. Nurses, physicians, social workers and other practitioners teamed together to overcome the inadequacies of a health insurance system designed to cover care delivered within an institutional setting. Case Management- thinking outside the box and coordinating care outside the walls Annette Watson was a registered nurse and utilization review manager for Blue Cross and Blue Shield plan in New England in the mid 1980s. Watson, now a vice president at URAC, was charged with initiating a case management program for the plan and remembers those early days as some of the best work I have ever done. It was gratifying, rewarding work, Watson said. We could see that case management resulted in better care and better outcomes for the patients. For example, Watson recalled working with a family of an infant who had been hospitalized on a ventilator for 18 months, unable to transfer to a home setting because the insurance plan only covered care in the hospital. Perhaps even more importantly, this kind of care had never been provided outside a hospital setting in rural New England. In those days, there was often no mechanism for providing specialized care in a less intensive setting or at home, because flexibility in benefits wasn t done yet, Watson said. Watson worked with the insurer, the family and providers to set the stage so that care could be delivered at home. As a result, the baby was the first in New Hampshire to go home on a ventilator and was a success story in every way. That case resulted in a positive long-term working relationship between the staff responsible for discharge planning at Dartmouth-Hitchcock Medical Center with the case managers at Blue Cross and Blue Shield of New Hampshire, and was an historic milestone, she said, noting the baby s care had already consumed one parent s $1 million lifetime benefit and was well on its way to reaching the other parent s $1 million coverage ceiling. To get that baby home was better in every way. Soon after, Watson and four other case managers formed the New England Association of Nurse Case Managers. That group is now one of the largest CMSA chapters and Watson remains a member. URAC accreditation of case management organizations is a stamp of quality. It validates to employers and to purchasers of those services that accredited organizations have the appropriate structure and policies in place to respect the role of the case manager and the role of case management. Case Management gains widespread adoption The late 1980s and early 1990s saw health care costs spiraling. Utilization management was tapped to keep costs in line, and case management took on new importance in an effort to balance quality patient care with cost control measures. Case managers working for insurers and hospitals coordinated patient care to both meet patients needs and to ensure efficient use of community and health care resources. These dual priorities matched the aims of organizations across the care continuum, and case managers nurses, social workers, therapists and rehabilitation counselors saw professional opportunities growing. In 1995, CMSA published the Standards of Practice for Case Management 3, which became the formal standards for the discipline. In that same year, the organization s board approved a peer-reviewed Ethics Statement on Case Management Practice 4, the foundation for applying ethical principles to the practice of case management. The two documents served to standardize the practice of case management, and were used by organizations as a baseline for job descriptions internationally. The Standards of Practice are held in courts of law as a standard against which case managers and their companies are held, Boling said. They are also incorporated into the various certifications available for individual case managers. Working with CMSA and building on the success of the Standards of Practice, URAC appointed a Case Management Advisory Committee to develop standards for organizations and launched Case Management Accreditation in URAC s Case Management Accreditation is the only standalone accreditation program that assesses the operations of case management services within a broad range of health care organizations.

3 ISSUEBRIEF3 URAC accreditation of case management organizations is a stamp of quality, Boling said. It validates to employers and to purchasers of those services that accredited organizations have the appropriate structure and policies in place to respect the role of the case manager and the role of case management. Why Accreditation Matters: Case Management Accountability According to Michael Garrett, vice president of business development for Qualis Health and a member of URAC s Accreditation Committee, accreditation of health care organizations serves three main purposes: To assure the quality of the organization or program; To assist in the improvement of the organization or program; and URAC ACCREDITATION SETS STANDARDS FOR HEALTH CARE ORGANIZATIONS URAC is the independent, non-profit leader in health care organizational quality improvement, offering accreditation and quality benchmarking activities for health plans, preferred provider organizations, medical management systems, health technology services, health call centers, specialty care, workers compensation, Web sites, HIPAA privacy and security compliance, and consumer education and support services. URAC has more than 500 organizations currently accredited in one or more of their 17 different accreditation programs. URAC is also the largest accrediting body of Blue Cross and Blue Shield Plans, with 29 Blues Plans holding one or more URAC accreditations. URAC currently offers quality improvement modules for: To establish accountability. 5 Qualis Health holds URAC accreditation in case management, utilization management and independent review. Garrett said organizations find value in accreditation based on the perspective of a variety of stakeholders consumers, customers, providers, regulators, legislators and health plans, as well as the organization s internal audience. Accreditation is valuable for marketing purposes, for liability protection, and to attract new employees, Garrett said. For instance, customers and consumers view accreditation as an indicator that an organization or program has oversight of case management activities. Accreditation is attractive to providers to participate in the provider network of an accredited health plan. Regulators and legislators view accreditation as evidence of an organization s integrity, accountability and quality management. Within the organization, senior management views accreditation as a risk management tool, or an operational audit of policies, procedures, protocols and processes that standards are in compliance. For employees, accreditation confirms that the organization has met nationally recognized standards, instilling a sense of pride within the organization and contributing to recruitment and retention. Accreditation raises the bar by educating and assisting organizations to meet nationally recognized criteria, Boling said. URAC takes the educational approach to organizational accreditation, rather than a reporting/measurement approach. As a result, the impact in case management, for instance, is that the industry is able to move forward towards adopting best practices. URAC accreditation and its continued movement to update standards leads in directing that momentum.

4 ISSUEBRIEF4 URAC S CASE MANAGEMENT 2005 STANDARDS REVISION RAISE THE BAR The 2001 standards continue to be required, but URAC s Version 3.0 of the case management standards will have some additional requirements of accredited organizations. One significant inclusion is that an organization have at least one quality improvement program that focuses on patient safety. The URAC Case Management Accreditation standards will continue to address critical operational categories for any quality case management program including: Staff Structure and Organization Staff Management and Development Information Management Quality Improvement Oversight of Delegated Functions Organizational Ethics Complaints Taking an educational approach to accreditation, URAC evaluates an organization s baseline operational level at the beginning of the review process. Written policies and procedures that include a definition of case management, the types of consumers served, the delivery model for case management services and case management staff qualifications are all required. Methods for determining caseload and staffing ratios are reviewed. Policies must also be in place demonstrating that licensed physicians are available for consultations with case managers and that continuing education meeting nationally recognized standards is available for all case managers. The URAC case management standards, which build on URAC s Core Accreditation Standards, enable organizations to successfully: Train case managers Identify individuals for case management Manage and conduct case management activities in an efficient and professional manner Promote the autonomy of consumer and family decision making Maintain confidentiality Delegate responsibility Demonstrate value In the case management industry, Boling said URAC accreditation establishes generally accepted best practice in the top line companies. Standardization is helpful in a very fragmented system in which everybody otherwise tends to do their own thing, she said. Watson affirmed that URAC constantly reviews its standards to incorporate trends in science, technology, and sophistication in their application within each discipline, and recently the case management standards have undergone revision to include a focus on process improvement around consumer and patient safety. URAC ACCREDITATION EMPHASIZES ORGANIZATIONAL QUALITY For the case management professional, URAC accreditation and URAC standards have served to reinforce important organizational process improvement programs and they have worked in support of professional standards that require the case manager to focus on best practices, Boling said. For example, a case manager may be well prepared to deal with a case involving a single working mom, who speaks English as a second language, with a child who is disabled and frequently hospitalized. The problems with maintaining the health care of that child at home and out of the hospital frequently involve more than medical issues alone. An organization that has not adopted the standards for case management may not permit a case manager to use the skills to deal with the underlying issues, she said. URAC s focus on best practices and ongoing quality improvement help to bolster and support the individual case managers advocacy in-house for a broader organizational view of their role and function in the organization. Watson said that in the early days, everyone wanted to jump on the case management band wagon, whether they were qualified or not. URAC Case Management Accreditation rapidly became the de facto indicator to customers and regulators that demonstrated quality practices were in place. URAC accreditation gave people who were contracting for services--employers, health plans, and other entities (Adapted from URAC s Web site,

5 ISSUEBRIEF5 the knowledge that the organization they selected was using trained personnel, that a written assessment and plan of care are developed, that written consent is obtained all the things that we take for granted now, Watson said. I believe URAC accreditation is a very big part of the success of the case management industry. For the most part, the bad apples are gone. The case management industry should be applauded for embracing self-regulation and quality improvement through accreditation. It is a great success story. A continuing evolution in case management- the changing role of the consumer The dramatic increase in appreciation for the value and importance of case management is one of the major changes Jeanne Boling has seen over the history of CMSA. We ve seen that appreciation elevated on every front, Boling said. Managed care organizations, hospitals, and now consumers are increasingly aware of the importance of case management. Case management is now recommended for the catastrophically ill or injured, or for those frequently hospitalized, or for those with chronic illness or disease, she said. Those cases which create the largest financial stress to the family are also generally assigned to a case manager now, Boling said. As disease management has reached those individuals with chronic conditions through educational efforts, consumers are becoming aware of the benefit of case management to assist them to navigate a very complex health care system. Boling said that self-referral in case management is a growing trend as well. Patients or their family members who have experienced the benefit of case management now request the services when a complex issue arises. With the introduction of more consumer-directed health insurance plans to the market, the need for case managers to assist consumers is likely to grow. There s a real opportunity for case management in consumer-directed health care offerings, particularly to guide the consumer through this maze of decisions they have to make, Watson said. It is already difficult to select a plan and make decisions before enrollment, such as how much money to put into a health savings account and how much to set as a deductible. Those aren t even decisions that are made in a crisis. When a person actually gets into a crisis health care decision-making situation, rational thought tends to go out the window. That s where case management comes in. URAC s new Consumer Education and Support Accreditation requires companies to provide information to consumers on the price and quality of health care options, as well as provide information for prevention and lowering health risks. Watson said case managers can assist in the process by serving as education and support experts consumers can rely upon. Watson noted there are many small, independent case management companies that are well placed to provide case management services via self-referral. The traditional role of a case manager as an advocate in a catastrophic situation lends itself to a similar role in a consumer-directed health care environment. I think we could see consumers turn to case managers in their own communities in the future for assistance in managing their care, whether they have a chronic condition, a catastrophic case, or in emerging new roles. A continuing evolution in case management technology as integrator In its 2001 Medical Management Trends and Industry Practices Survey, URAC found that advances in technology were leading a trend within medical management to integrate utilization management, disease management and case management services to provide better care outcomes. In its 2005 Medical Management follow-up study 6, URAC found even greater integration of staffing and operations due to information systems that allow companies to track patients across the different medical management interventions. The result is more efficient use of staff and less overlap for patients in the system. Qualis Health adopted an integrated care management system for its utilization management and case management teams in Garrett said There has often been an intermediary between the case manager and the client, such as the health plan or employer. In a consumer-directed model there may be an opportunity for a direct relationship between consumer and the case manager. In the future, we may even see the consumer hire the case manager directly.

6 ISSUEBRIEF6 the company is now in the process of migrating to a whole new medical management information system that is patient-centered and allows for more care management services to be offered and integrated. We re making an enormous investment in technology to meet the needs of our customers and other stakeholders, he said. Efficiency and provider satisfaction are the primary reasons why we reorganized our model seven years ago around market segments. Historically, case managers and utilization managers operated in separate silos. Ten years ago, case managers were quick to point out that case management was not utilization management. Then we reorganized around our customer base, so we now have a Medicaid team, a worker s compensation team, and a self-funded health plan team. These team members now work together in delivering all our services to meet the needs of the patients while collaborating with providers and others. Boling said the increase in integration of medical management strategies utilization management, disease management, case management, health call center and health coaching blends into an overall care management model. Integration provides the opportunity to take the best of what those separate and previously siloed disciplines has brought to the health care system, and combines them efficiently so consumers have a single point of contact, Boling said. Predictive modeling has become an important part of many medical management efforts, enabling companies to identify those potentially at risk more effectively and to design early interventions. That enables the case manager to have an impact on prevention as well as management of illness, Boling said. Preliminary findings of URAC s 2005 Medical Management survey has identified service integration, predictive modeling and evidence-based medicine as methods to improve outcomes in the coming years. We have to demonstrate what has been done to improve the economic, clinical and patient satisfaction outcomes in this industry, and I think the industry has to become better at doing that in a standardized way so we can compare performance. Technology is going to revolutionize the health care industry, Garrett added. Greater use of telehealth services and the use of web-based channels to reduce costly on-site visits will reduce the cost of case management. The adoption of electronic medical records over the next three to five years will allow care professionals immediate access to standardized clinical data and improve physician communication. Look for care managers to work jointly with physicians from physician practice offices utilizing an electronic medical record to help meet the demands of pay for performance systems required by the Centers for Medicare Services, Boling said. Outcomes will improve exponentially as the patient treatment team works together toward better outcomes with clinical and financial information shared by all. More evidence of improved outcomes, return on investment in the future Companies are still looking for strong evidence of improved outcomes and return on investment for medical management interventions. All the care interventions will have to increasingly prove their value, based on scientific evidence-based data, Garrett said. We have to demonstrate what has been done to improve the economic, clinical and patient satisfaction outcomes in this industry, and I think the industry has to become better at doing that in a standardized way so we can compare performance. Garrett noted that investment in new technology within the industry must include outcomes reporting for case management services that smoothly interface with payer and provider systems. I think you re going to have to be a big player in the field to remain in the field, because it is going to take a big investment in technology to stay competitive, he said. As an answer to the call from payers and purchasers for demonstrated value in case management, CMSA released Case Management Adherence Guidelines (CMAG) 7 in October, 2004, based on concepts presented by the World Health Organization 8 and designed to help case managers aid in the assessment, planning, facilitation, and advocacy of patient adherence. The guidelines come with a software companion, the

7 ISSUEBRIEF7 CMAGTracker, so case managers can enter data and track their interventions and adherence improvement. Participating case managers can also take part in ongoing research measuring adherence and health behavior change based on the new guidelines. The demand for outcomes data has always been strong, Boling said. In the past, return on investment measurements have been performed according to proprietary formulas, making it impossible to compare various statistics. The Case Management Adherence Guidelines and their associated database measure the direct outcome of case management intervention in terms of patient adherence to recommended treatment. The tools are already widely accepted and hold great promise to provide the data case managers, employers, payers, providers and consumers need to determine the comparative value of case management. CMAG and the CMAGTracker mark the first significant national research initiative launched in case management, and Boling said she expects numerous research projects probing the impact of case management and patient adherence to result from the new availability of data. From URAC s perspective, the implementation of CMAG within a case management organization has the potential to meet URAC requirements for a patient safety quality improvement project. Beyond CMAG, Watson said case management has the potential to play an active role in improving patient safety, especially pointing to the relationship between the case manager and client to reduce medication and other preventable medical errors through education and counseling and enhanced communications. In 2004, URAC studied how medical management organizations have responded to the 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm. Results of the study, funded by the Robert Wood Johnson Foundation, were released in a URAC white paper called Translating the Quality Chasm Aims Into Medical Management Practice: Implementation and Measurement Strategies. Among the study s ten key findings and recommendations for promoting the aims of Crossing the Quality Chasm, several pointed directly to the work of case managers: Promoting patient safety by supporting care coordination across many settings and through administrative oversight. Engaging patients to increase health care knowledge, support self-management, and empower decision making is necessary for the system to meet the IOM s six aims; and Promoting patient centeredness such as individual preferences and cultural attitudes. CMAG and other technical advances have improved the industry s focus on measuring outcomes and demonstrating the value of case management, Watson said. Value is found not only in terms of dollars and cents but can be further quantified through improved health status and outcomes, higher patient satisfaction, and enhanced patient care. In a way, these systems for quantifying outcomes are proving what we already knew by instinct: that doing the right thing for the patient is always the right thing to do. As both URAC and CMSA celebrate their 15 year anniversaries, Watson noted that collaboration between the two organizations has promoted the mutual goals of URAC and CMSA, to the benefit of all. While CMSA focused its efforts on the standards of practice for the individual case manager, URAC focused its efforts on standards of practice for organizations that were providing case management services, she said. Because of those two tandem activities developed in an atmosphere of collaborative communication and with a common goal, together we have achieved the transformation of case management into an integral part of the total health care delivery system. "Because of those two tandem activities developed in an atmosphere of collaborative communication and with a common goal, together we have achieved the transformation of case management..."

8 ISSUEBRIEF8 About URAC URAC, an independent, non-profit organization, is a leader in promoting health care quality through accreditation and certification programs. URAC s standards keep pace with the rapid changes in the health care system, and provide a mark of distinction for health care organizations to demonstrate their commitment to quality and accountability. Through its broadbased governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in setting meaningful standards for the health care industry. For more information, visit About Qualis Health Qualis Health is a URAC accreditied, private, nonprofit health care quality improvement organization that generates, applies, and disseminates knowledge to improve the quality of health care delivery and health outcomes. Founded in 1974, Qualis provides care management and quality assessment/improvement services to health plans, employers, trusts, third party administrators, workers compensation, and government agencies. About CMSA Established in 1990, the Case Management Society of America has over 9,000 members and is the only international non-profit 501(c)(6), multi-disciplinary, professional organization dedicated to the support and advancement of the case management profession. Since its inception, CMSA has been at the forefront of setting professional standards for the industry, which allows for the highest level of efficiency and integrity, as well as developing national and local leaders who are recognized for their practice and professional excellence. Resources [1] From Standards of Practice for Case Management, Case Management Society of America, [2] Ibid. [3] See [4] See _http:// ( [5] From Understanding Accreditation, by Michael B. Garrett, MS, CCM. Case Management, Vol. 7, No. 5, Oct. 2001, pp [6] URAC s Trends and Practices in Medical Management: 2005 Industry Profile includes results from a survey of 284 companies, company interviews and focus groups. The final report will be released in October, [7] Found online at [8] Adherence to Long-Term Therapies. Evidence for Action, a report from the World Health Organization, July, [9] The report is available online at L Street, NW, Suite 400, Washington, D.C Phone (202) Fax (202) Copyright URAC 2005 URAC Issue Brief! is written and produced by Health2 Resources Katherine H. Capps, President 344 Maple Ave West, Suite 245 Vienna, VA Phone (703)