Health care grows increasingly complex, the population is aging, IssueBrief

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1 IssueBrief VOLUME 3, ISSUE 1 Cultivating the accountable case manager: New models of care, increased demand make robust workforce development essential Health care grows increasingly complex, the population is aging, and the need for professional case management has never been greater. That presents a tremendous opportunity for the professional case manager. It presents a similarly tremendous challenge for the industry, especially those who hire professional case managers. How do they recruit, hire and train the right people? Case managers provide a wide range of critical services as part of the health care delivery team, including designing and monitoring care plans; coordinating care provided by multiple physicians and other providers; facilitating communication among the patient, family, clinicians, doctors, hospitals, payers and others; evaluating patient progress; and tracking outcomes and patient satisfaction. The Commission for Case Manager Certification TM (the Commission) defines case management as a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options New models of care that emphasize care coordination require a robust cadre of professional case managers who are current, skilled and well-suited to the demands of the position. The industry must start identifying and preparing that cadre now. The question, however, is how?

2 and services required to meet the client s health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. With this understanding of the case management process, it becomes clear: New models of care that emphasize care coordination require a robust cadre of professional case managers who are current, skilled and well-suited to the demands of the position. The industry must start identifying and preparing that cadre now. The question, however, is how? Hiring the right professional case manager is not a simple task. Case management functions are not responsibilities employers can afford to delegate to just anyone. When organizations measure outcomes such as the rate of hospital readmissions or whether transition services were appropriate, they need professionals in place who have advanced knowledge, training and expertise. Accordingly, employers need to hire or cultivate skilled, knowledgeable and competent case managers. Likewise, as their role becomes more prominent, case managers need to understand what they must do to stay at the top of their profession. And finally, the health care industry needs to recognize the need to ensure an adequate supply of professional case managers to meet the everincreasing demand. Supply, demand and uncertainty There are roughly 100,000 case managers practicing in the U.S. today; more than 30,000 are board-certified, said Hussein Tahan, DNSc, RN, knowledge editor, Case Management Body of Knowledge TM (CMBOK ) and executive consultant for the Commission. Tahan, who has conducted extensive research into case management workforce issues, explained that the available data from the Commission and various other sources suggest current demand significantly outpaces supply and will continue to grow, given the emphasis on care management and care coordination in the Affordable Care Act. And the supply may be dwindling. As illustrated in figure 1, the case manager population is aging. Moreover, changes in academia over the last 20 years may be contributing to the shrinking talent pool. Why no standardization? There is no standardized curriculum, no single accepted approach to training case managers; the training they receive is primarily on the job, Tahan said. Today, there are far fewer academic case management programs than there were in the 1990s. For instance, many of the academic programs in nursing schools have shifted from case management to advancedpractice nursing to meet the demand for nurse practitioners. He expects the pendulum will eventually swing back and more Figure 1. Age Distribution Range f % , , , > Prepared by: Hussein Tahan, DNSc, RN, for CCMC CMLearning Network TM webinar Source: CCMC s Role & FunctionS Study, 2009 (numbers are rounded) academic case management programs and classes will become available especially online. Moreover, consider that case management is a cross-disciplinary and interdependent specialty practice. Case managers come from different backgrounds, including nursing, medicine, social work, rehabilitation counseling, workers compensation, and mental and behavioral health. Thus, they have differing experience and education. So those who hire case managers face a dilemma: How do they find the right people right now? Clearly, employers cannot afford to focus on hiring only experienced case managers; there simply are not enough to go around. 2

3 The solution: Hire for potential and provide the necessary training. Recruitment and selection We need to hire for the long term, Tahan said. Because of the limited supply, we may be tempted to compromise, to settle. But ultimately that affects retention, he said. It can also have a deleterious impact on patient care. The lack of supply does not justify compromising on quality, but it does mean employers must pay careful attention to the recruiting, interviewing and onboarding processes. Hiring the right case manager is not necessarily about finding someone with a specific knowledge base, he said. Case management is both art and science; a good case manager has characteristics beyond what a résumé or licensure can convey. A résumé can help identify whom to interview, but beyond that, selection becomes much less cut and dried. (See sidebar on page 4 for tips on locating case manager candidates.) Hire based on a candidate s values (e.g., patient-centered care, empathy, caring, compassion, advocacy, loyalty, belief in ability to succeed and cultural sensitivity) rather than simply on his or her knowledge base, Tahan counseled. The right person can be trained for management knowledge, skills and competencies. The interview is crucial. Employers should use the interview not as much to assess theoretical knowledge, but how the candidates will practice case management. Ask open-ended questions about how they handled a particular situation, how they acted in that situation, what outcome they were able to achieve. Ask for several specific, detailed examples. Tahan offers the following guidance to employers who interview for case manager positions: Probe how candidates understand their relationships with other providers. How aware is a candidate about the interdependency of the case manager role? Is she better at problem solving in isolation, or does he prefer to work collaboratively? Professional case managers approach the provision of casemanaged health and human services in a collaborative manner, working with professionals from within or across health care organizations (e.g., provider, employer, payer and community agencies) and settings, working together closely for the benefit of clients and their families or support systems. Ask specifically about how they deal with stress, and address conflict. A case manager is troubleshooting almost all the time and must be able to function under stress. She must be able to persevere until satisfactory resolution is achieved. Assess cultural competence and sensitivity. Cultural competence doesn t simply apply to dealing with individuals from different ethnic backgrounds; different work settings have different cultures, too, and the case manager needs to know how to navigate those differences whether related to the clients she serves or the practice environment. Consider the client and family perspective. Does the interviewee come across as patient-centered, compassionate and empathetic? Does he convey a practical understanding of the case manager s role as client advocate? Assess leadership potential. In the case manager role, leadership skills become more prominent. For instance, moving from a nurse to a nurse case manager involves moving from primarily clinical skills and knowledge to leadership skills and competency. A case manager position demands a person with different capabilities and temperament than does a traditional nursing or social work job. Identify desirable personality traits. These include customerorientation, honesty, resilience, We need to hire for the long term. Because of the limited supply, we may be tempted to compromise, to settle. Hussein Tahan, DNSc, RN, knowledge editor, CMBOK; executive consultant for the Commission 3

4 21st Century Recruiting To recruit potential case managers, look in nontraditional places, Tahan said, places where we haven t advertised before. Among his recommendations: Make more and better use of social media to connect with candidates. Consider hosting a virtual (online) open house. Don t blindly hire a recruiting or search firm. Engage partners with special knowledge in your search for talent traditional search firms may not have the background in case management. Be flexible and create roles for the talent you come across rather than try to locate the talent that will fit an existing role you have vacant. Work with professional societies related to case management. (The Commission recently launched its Career Center, where case managers can browse for jobs and employers can post opportunities. The Commission s Career Center offers nationwide access to a vast number of health care professionals, by simply creating an account.) warmth, patience, perseverance, open-mindedness, acceptance of constructive criticism, ability to be non-judgmental and non-critical, willingness to learn, risk taking, assertiveness and practicality. Identify appropriate skills. The skills the ideal case manager candidate has should include emotional intelligence, leadership, accountability, critical thinking, negotiation, brokering, teamwork, collaboration, cooperation, conflict resolution, time management, priority setting, cost-benefit analysis and strategic decision-making. Probe for the ability to manage seemingly conflicting priorities. A case manager working for a payer in utilization management will face situations when the goals of the insurer and provider conflict, and the case manager will be in the middle. How would the candidate navigate this all-too-common situation? (For insights on how the CCM credential can help case managers navigate these sometimes-treacherous ethical waters, see the discussion about the value of case manager certification.) Look for a willingness to learn. When the candidate explains how he or she went about meeting goals (e.g., resolving a challenging situation or implementing a new care process), the desired candidate should not be one who is reluctant to admit what was lacking and how he or she sought to fill the gaps. Such transparency not only demonstrates that the candidate is open to learning and able to admit needs, but is able to show confidence, self-esteem, honesty and transparency as well, all of which are desired values in a case manager. Orientation and onboarding Identifying the right candidate represents the beginning of a process. Unfortunately, those who hire case managers often overlook or fail to give adequate attention to the onboarding process, Tahan said. Orientation is essential: It s easy to assume a case manager with 10 or 15 years of experience will understand the role and won t need to be trained. But that s not the case, according to Tahan: Expectations and requirements vary from one work culture to another. Helping the newly hired case manager to transfer existing knowledge, skills and competencies to the new practice environment and to learn new ones is a strategy for long-term success, he said. Orient new hires well to the roles and responsibilities, the job description and the expectations that go with the position. Even for the most experienced and skilled case manager, adjusting to a new culture can be stressful, he said. Take the time to make sure you are making them, during that transition period, as comfortable as they need to be in the new work environment. Make time to answer questions, offer guidance and review performance. And, from the outset, provide ongoing training and education. Professional development On-the-job training must be formalized, evidence-based and woven into the fabric of the organization, Tahan said. The industry is already moving in that direction. In January 2012, Horizon Healthcare Innovations launched a specialized training program for nurses working in 4

5 Horizon Blue Cross Blue Shield of New Jersey s patient-centered medical home programs. Horizon is investing more than $1 million to fund the training program and provide payments to medical practices so they can afford to hire care coordinators. The 12-week course, which involves face-to-face and online sessions, trains nurses to become population-care coordinators. Almost 40 nurses are undergoing the training, and Horizon hopes to train a total of 200 nurses over the next two years. 1 These are not case managers, per se, but Horizon s commitment to training nurses for new models of care is an approach to be emulated, said Patrice V. Sminkey, RN, the Commission s chief executive officer. One excellent way to train new case managers is through a formal mentor program. For the case managers themselves, this should be nothing out of the ordinary: Mentoring, Tahan explained, is part of the profession. As a case manager, one of my professional obligations is to mentor others into the role. attend conferences and webinars; and become involved in scholarly activities, such as writing for publication, presenting at conferences or developing performance-improvement or research projects. Such activities are not ancillary; they are integral to the profession and should be incorporated into expectations and performance evaluations, he said. The CMBOK One tool to advance education and help case managers stay current is the CMBOK, an online knowledge resource for all key case management processes (screening, assessing, stratifying risk, planning, implementing, followingup, transitioning, communicating post transition and evaluating) and knowledge domains. Employers can use the online, searchable reference to guide daily practice of case management for workforce published. The CMBOK is updated continually. Board certification ensures competence The best way for an employer to ensure a competent, up-to-date case manager workforce is to hire board-certified case managers and/or promote board certification among its current cadre of case managers, Sminkey said. Board certification informs some of the less obvious aspects of the profession. Many case manager positions require an individual who can competently deal with difficult ethical questions every day. The Commission gives clear guidance on ethical issues in our Professional Code of Conduct for Case Managers such as these; candidates for those positions should definitely be steered toward certification, she said. The CCM credential means that case managers are committed to upholding the highest professional and ethical standards. He offered a variety of approaches to evidence-based education and training. For example, case managers should be encouraged to return to school for graduate education; "The CCM credential means that case managers are committed to upholding the highest professional and ethical standards." Patrice Sminkey, RN, chief executive officer, The Commission participate in professional organizations; 1 Rutgers, Duke, Horizon form education partnership for nurses, NJ BIZ Feb. 01, 2012; Blues Horizon invests $1M to train medical home care coordinators : FierceHealthPayer, Feb. 3, development. It addresses one of the challenges to training potential case managers: Because the science, practice and policy of case management are changing rapidly, textbooks and journal articles may be obsolete before they are Employers are increasingly recognizing the value of the CCM credential. Promoting board certification as part of workforce development benefits everyone the employer, the other team members and the client. In 5

6 fact, the Commission s 2009 Role & Functions Study found that a growing number of employers require case management certification (36 percent, compared to 26 percent in 2004), and more employers offer additional compensation for certification (27 percent in 2009 compared to 20 percent in 2004). 2 Sminkey offered two examples: Bon Secours Virginia Medical Group uses embedded case managers as part of its primary care team. Each is either board-certified or preparing to take the exam. (For more on Bon Secours, see the Commission issue brief, Communicate, engage, transform: Bon Secours case managers part of a robust team enhancing health care delivery and patient health available at Last year, the U.S. Department of Veterans Affairs announced the CCM exam was reimbursable under the GI Bill for licensing and certification. The CCM is also an approved certification for the Magnet Recognition Program, which recognizes health care organizations that provide nursing excellence. Learning continues after certification, Tahan said, and continuing education can be as rigorous and diverse as the employer and the case manager want to make it. He counseled thoughtfulness. Don t keep going to the same programs and topics discover what is 2 Key Finding from 2009 CCMC Role & Functions Study. out there that will improve your practice and keep you current. The competent, accountable case manager Such programs, if successful, will help professional case managers develop a set of competencies that allows them to perform effectively in their roles and meet the expected goals and objectives. Tahan groups these competencies into five categories: 1. Clinical care management, which includes application of the case management process, client assessment and care planning, clinical knowledge in the specialty area of practice, health education and instruction. 2. Management and leadership, which focuses on coordination, facilitation and negotiation of care activities and interventions, acting as a team leader or facilitator, advocacy for the client/ support system, brokerage of community resources, effective interpersonal communication and problem identification/resolution. 3. Financial acumen, which addresses, among other things, cost-benefit analysis and return on investment, appropriate utilization of resources, and engagement in cost-reduction or revenueenhancement activities. 4. Information management, which demonstrates, for example, dissemination or transfer of information at the right time and to the right people (e.g., client, caregiver, health professionals), data collection analysis and reporting (e.g., safety and quality measures) and use of health information technology. 5. Professional development and scholarship activities that focus on the case manager s responsibilities to the profession. These include research, evidence-based practice, participation in professional organizations, sharing of new knowledge or practice innovations and life-long learning. The impact of reform The Affordable Care Act strengthened the importance of these competencies but also raised the importance of, and introduced, new ones, Tahan said. Care outcomes and patient satisfaction with care have taken a front seat and now affect the bottom line more than ever. Competent, knowledgeable and skilled case managers are able to foster better outcomes; that enables an organization to reduce financial risk or even increase revenue streams, he explained. Reimbursement models are changing, with payers moving toward global, capitated and bundled reimbursement structures rather than covering single 6

7 episodes of care. It represents a move away from fee for service and leads to paying for value. Therefore, Tahan said, financial competency becomes more significant because of the focus on value-based purchasing wherein cost-benefit analysis, return on investment, clinical and safety outcomes, as well as client s experience with care, matter. Reimbursement continues to evolve, Tahan said. Right now, value-based purchasing is focused on outcomes. The next generation of reimbursement models will focus on workforce dynamics and workforce skills and competency. This potential shift prompts employers to be ready and prepare case managers today for their future roles. The advent of new models of care under health reform in particular, the medical home and accountable care organizations have thrust care coordination center stage. And that changes the provision of care. Patient-centered care has expanded to include the patient, the family and the patient s social network. Likewise, care delivery has expanded; multidisciplinary care teams deliver care across a continuum, and managing transitions of care across various settings has become an essential part of care delivery. In fact, he noted, candidates for case management roles are often assessed based on their views of the care services continuum, and ability and willingness to focus on the management of the client s care across that continuum. Keeping current, moving forward Such changes demand the ability to foster collaboration, cooperation, communication a sweet spot for professional case managers. And it means case managers will have to work to the top of their license. The role of the case manager is going to be increasingly visible, increasingly important and increasingly sensitive to outcomes, Tahan said. With this increased visibility comes greater vulnerability and exposure, he warned. Case managers will not be able to slip under the radar. Each will be more accountable than ever. As a case manager, I should keep current. I must understand what is changing in my industry and how that affects me. I need to identify gaps in my skills and knowledge and actively pursue closing those gaps. I have to be an active participant in my own education, he said. Case managers need to keep up with the dynamic health care environment, he said. Of special significance are the new laws and regulations, changes in accreditation standards, practice innovation, and health information technology such as case management and predictive modeling software applications. Case managers should keep abreast of these changes, attend regional or national conferences and participate in professional associations/societies as vehicles to remain current about the industry. They should also consider pursuing graduate-level specialty education to expand their theoretical and practical knowledge, which ultimately enhances practice and performance. Change is the one constant in the industry right now, agreed Sminkey: Because of changing demographics, the growing prevalence of chronic disease, heightened concerns about cost and, perhaps most significant, new and emerging models of care, it is a time of transition and transformation. We re seeing a convergence, she said: Policy makers, health care professionals, payers and other thought leaders are focused on making health care safer, more efficient, effective, coordinated and patient-centered in other words, achieving the Triple Aim: better care for individuals, better care for populations and lower health care cost trends. Case managers have a central role, she said. For individual health care organizations and the health care industry at large to achieve the promise of the Triple Aim, we must have a skilled, competent and nimble workforce in place, and that requires renewed attention to workforce development, Sminkey said. With trained, professional and, ideally, boardcertified case managers in place, we can move forward to control costs, improve outcomes and heal our broken health care system. It needed to be done yesterday. n 7

8 About the Experts Patrice Sminkey, RN chief executive officer The Commission for Case Manager Certification Hussein Tahan, DNSc, RN independent consultant and researcher International Health Care Management & Consulting, New Jersey and knowledge editor, CMBOK Sminkey comes to the Commission from URAC, where she most recently served as senior director of sales. Prior to that, she was senior vice president, operations and client management, Patient Infosystems in Rochester, N.Y. She brings a proven track record in operations management in small and large operations, multilevel services and cross-functional teams. She has extensive experience in client management and coordination, including marked improvement in client retention, timely and fiscally sound program implementation and an expanding book of business. As chief executive officer, Sminkey oversees the management of all activities related to the Commission s operations, including all programs, products and services; and the provision of quality services to and by the Commission. She is a direct liaison to the Commission s Executive Committee. She works with the Commission s volunteer leadership to evaluate and develop potential new products for implementation by the Commission, and she establishes and maintains communication and working relationships with other organizations, agencies, groups, corporations and individuals. She holds a diploma of nursing from the Chester County School of Nursing. Tahan is a respected public speaker, educator and researcher and has published more than 80 articles. He is the co-author of CMSA s Core Curriculum for Case Management and Case Management: A Practical Guide for Practice and Education and is currently a member of the editorial advisory board of the Professional Case Management journal. As a leader in health care with more than 20 years of experience, Tahan s case management career began in the early 1990s with completion of his MS in Nursing Administration and the research he conducted on roles and functions of case managers. An active member of the Greater New York Chapter of CMSA for more than 10 years, he serves on national taskforces, including the NTOCC Measurement Group, URAC Measures Advisory Group, and the AHRQ-funded case management outcomes study conducted by the Oregon Evidence-Based Practice Center. Tahan conducted the 2004 and 2009 Commission research on roles and functions of case managers. He is also a past chair of the Commission. Tahan is knowledge editor for the CMBOK and executive consultant for the Commission. Join our community of professional case managers! Commission for Case Manager Certification Commerce Parkway, Suite C n Mount Laurel, NJ n (856) [email protected] n Written and produced by Health2 Resources. Copyright 2012, CCMC