Nursing Case Management Role Delineation Study National Survey

About this Report This report pertaining to the practice of nursing case management was based on the results of a 2013 national study of ANCC board-certified nurse case managers. Copyright 2013 American Nurses Credentialing Center, All Rights Reserved

Table of Contents ACKNOWLEDGEMENTS... 3 BACKGROUND... 4 ROLE DELINEATION STUDY OVERVIEW... 4 UPDATED TEST CONTENT OUTLINES... 4 ROLE OF THE CONTENT EXPERT PANELS... 4 SURVEY METHODOLOGY... 5 SURVEY CHRONOLOGY... 5 SAMPLE SELECTION... 5 SURVEY DEVELOPMENT AND MEASURES... 5 SURVEY RESULTS... 7 DATA COLLECTION... 7 DATA ANALYSIS... 7 DESCRIPTION OF SURVEY RESPONDENTS... 8 PRACTICE DESCRIPTIONS... 8 APPENDICES DOMAINS AND TASKS... APPENDIX A DEMOGRAPHIC VARIABLES... APPENDIX B SUMMARY TABLE... APPENDIX C CHARACTERISTICS OF SURVEY RESPONDENTS... APPENDIX D TASK STATEMENTS SORTED BY FINAL VALUES OF RISK... APPENDIX E Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 2

Acknowledgements The American Nurses Credentialing Center (ANCC) wishes to thank the content experts who served on the 2013 Nursing Case Management Role Delineation Study panel for sustaining this effort and producing a role delineation study of such high caliber. Without their numerous hours of input and feedback, the study would not be possible. We also would like to thank the ANCC and Castle staff who also spent numerous hours working to make this study possible. Finally, we would like to thank the nurses, ANCC-certified in nursing case management, who supported this study by completing the survey questionnaire. The contributions that all of these people made to the study were essential to its success. Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 3

Background The American Nurses Credentialing Center (ANCC), which was incorporated in 1991 as a subsidiary of the American Nurses Association, is the largest nursing credentialing organization in the United States. Its vision is to drive nursing excellence, quality care, and improved outcomes. ANCC currently offers 25 examinations at various levels, including diploma and associate degree, baccalaureate, and advanced practice for nurse practitioners, clinical nurse specialists, and other disciplines. More than 19,000 candidates took an ANCC certification examination in 2012. In addition to certification, ANCC provides services such as the Magnet and Pathways to Excellence recognition programs for hospitals and other facilities that demonstrate excellence in nursing services, accreditation of continuing education programs, education and consultation services, and outreach to nursing organizations around the globe. Role Delineation Study Overview Role delineation or job analysis studies are typically carried out at the national level with the goal of describing current practice expectations, performance requirements, and environments. ANCC has a current goal of conducting a study of each specialty approximately every three years to capture changes in work activities and the knowledge and skill areas required to perform those activities. The findings are used to update the content of its respective certification examinations. The 2013 Nursing Case Management Role Delineation Study involved two sets of processes or activities that ran more or less concurrently: a national Web-based survey and a linking activity. The national survey was designed to collect information on the work activities nurse case managers perform in practice, while the linking activity identifies the major knowledge and skill areas required to perform the work activities listed in the survey. The results of both of these processes were used in the updating of the test content outlines for each examination contained within the study. Updated Test Content Outlines The results of this role delineation study were used for updating the test content outline for the Nursing Case Management examination. Examination forms that are produced based on the Nursing Case Management examination content outline developed through this study are scheduled to go into effect October 25, 2014. A copy of the test content outline is available on the ANCC website. Role of the Content Expert Panels Throughout the study, ANCC invited professionals in practice and educators who teach courses relevant to nursing case management to serve on a content expert panel. The panels developed the work activities and demographic items for the survey, linked knowledge and skill areas to the work activities list, and finalized the test content outlines for the certification examination. All of the content experts serving on the panels were certified by ANCC in nursing case management and were invited to serve on the panel based upon their expertise in the specialty. Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 4

Survey Methodology The purpose of the development and administration of the national survey was to collect information on the work activities those working in nursing case management perform in practice. The role delineation study panel met for three days, May 13-15, 2013, to draft a pilot version of the survey and to construct the initial map of knowledge and skill areas relevant to the work activities included in the survey. Survey Chronology The survey development and administration timeline was as follows: May July 2013 The role delineation study panel along with staff from ANCC drafted the survey. The survey was pilot tested and revised. August September 2013 The final survey was administered on the Web. October November 2013 The survey activity results were analyzed, and activity weights were determined. Each panel met to review the survey results and activity weights. Sample Selection On January 1, 2013, there were approximately 816 nurses ANCC board-certified in nursing case management with valid email addresses. Fifty of these nurses were randomly selected to participate in the pilot survey. The rest were invited to participate in the national survey. Survey Development and Measures On May 13-15, 2013, the role delineation study panel met in Silver Spring, Maryland, to draft the national Nursing Case Management Role Delineation Study survey for the 2013 role delineation study. The panel members reviewed the work activities that had been used in the ANCC's previous nursing case management role delineation as well as Standards of Practice for Case Management (CMSA, 2010). They also discussed any additions, deletions, and changes they would make to update the previous work activity list to reflect current practice of nursing case management. As a result of this meeting, the panel reached consensus on a list of 61 work activities, also known as task statements, to be used in the 2013 survey. These work activities were divided into seven domains: (1) Assessment, (2) Planning and Collaboration, (3) Implementation, Coordination, and Linking, (4) Education, (5) Advocacy, (6) Evaluation, and (7) Systems. The complete text of the work activities list is presented in Appendix A. The panel also identified and finalized a set of 16 demographic questions (see Appendix B). During the same meeting, the panel reviewed and approved three scales that respondents would use to rate the work activities listed in the survey Frequency (the frequency with which a work activity is performed), Performance Expectation (how soon on the job the performance of an activity is expected), and Consequence (the consequence of performing an activity incorrectly). The Performance Expectation scale was specifically Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 5

designed to distinguish entry-level skills. These three questions and the instructions for answering them are presented in Table 1. Table 1. Survey Questions for Rating Work Activity Statements Performance Expectation: At what point in the career is the newly certified Nurse Case Manager expected to perform the task? Not at all After the first six months of certification (does not include exactly six months) Within the first six months after certification (includes exactly six months) Example: Certified public accountants are expected to conduct financial audits in the first six months after certification, but client management would be performed later in the career. Consequence: To what degree would the inability of the newly certified Nurse Case Manager to perform duties in each performance task be seen as causing harm to stakeholders? (Harm may be seen as physical, psychological, emotional, legal, financial, etc.) No harm Minimal harm Moderate harm Substantial harm Extreme harm Example: It is critical that workers on high-rise buildings maintain a grip on their hammers. (Failure injures the public walking below and impacts other stakeholders such as employers, insurers, etc.) Frequency: Frequency refers to how often the newly certified Nurse Case Manager performs duties in each of the performance tasks considering a one-year period. The following scale is used to record Frequency: Never Rarely Sometimes Often Repeatedly Example: Flight attendants open soft drinks for passengers repeatedly, yet this job duty is neither important nor critical. The study design included the panel review of Performance Expectation and the computation of a value, Risk, defined as the product of Frequency and Consequence. High values of Risk were associated with high values of both Frequency and Consequence whereas low values were associated with low values of those two measures. Although Performance Expectation was not used in the computation of Risk, the values of Performance Expectation were reviewed by the panel, resulting in the exclusion of some activities from the final list of performance tasks and test content outline. As such, Performance Expectation was treated as more critical than the measures of Consequence and Frequency. This scheme emphasized the work activities that are required of newly certified specialists and have the greatest impact on public health or safety. Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 6

Survey Results Data Collection Pilot Testing. Using the same procedures intended for administering the national data collection, the survey was piloted in March 2013. Fifty nurses ANCC board-certified in nursing case management were randomly selected from across the nation to take the pilot survey. Overall, 18 (36%) of those invited to take the pilot survey responded. The respondents of the pilot test in general indicated that the work activities were appropriate and reflective of the job of nursing case management. During the review of the pilot survey results, the role delineation panel made minor adjustments to the demographic questions used to demonstrate the characteristics of the respondents. National Survey. In April 2013, the remainder of those nurses ANCC-certified in nursing case management (766 nurses) were sent notifications via the United States Postal Service (USPS) and email. In addition, a follow-up reminder letter was mailed through USPS, and email reminders were sent on about a weekly basis. The notifications explained the purpose and importance of the study, the eligibility criteria of the study, and how to access the survey via the Internet. The letters also indicated that the participant s responses would be kept confidential. In addition, the notifications indicated that respondents completing the survey would receive a five-hour reduction of their continuing education requirement for their ANCC recertification. The reminder letters were sent only to those who had not yet responded to the survey. At the end of the survey, 329 (43%) nurse case managers had submitted results. Data Analysis The ratings of Performance Expectation were not used numerically in the computation of the test specifications. The role delineation panel evaluated the measures of Performance Expectation during the review of the survey results. Tasks for which the distribution of Performance Expectation ratings showed a substantial number of ratings of 1 and 2 were removed from the list of tasks appropriate for inclusion in the certification examination for nursing case management. It should be noted that the role delineation panelists anticipated removing some tasks because they were unable to reach consensus on expected entry-level performance of those tasks during the initial study, and they felt it would be better to defer the decision until they could review the survey data. To compute the weight of each task, a quantity, Risk, was defined as the product of Consequence and Frequency. All the values of Risk are added, and this sum becomes the divisor for each value of Risk to produce the Weight of the task. (Weight is the normalized value of Risk, and the sum of all weights is one.) The values of Weight represent the fraction of the exam that will pertain to the associated task. (Multiplied by 100, these weights become percentages.) These data were reviewed in detail in the second role delineation study panel meeting, held October 23-25, 2013. In particular, panelists examined the mean Performance Expectations ratings of the tasks to determine if the survey respondents considered a task too Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 7

elementary or too advanced for inclusion on the examination. For those tasks so identified, the value of Risk was changed from the computed value to zero so that the task would add no weight to the final test content outline. These data are presented in Appendix C. Description of Survey respondents The survey respondents reported being, generally, female (96.7%) and white (79.8%). They were well educated, with over half (51.1%) reporting a bachelor s degree and nearly one-quarter (21.9%) reporting a master s degree, both in nursing. Almost one-fourth (24.6%) reported degrees outside of nursing, with 31.2% reporting a master s degree and 44.2% reporting a bachelor s degree. The respondents also reported holding a variety of other certifications. Almost half (47.7%) of the respondents reported being between 50 and 59 years of age, with an average of 25.39 years working as a registered nurse and 11.46 years working in nursing case management. The respondents reported being certified in nursing case management an average of 4.58 years. The vast majority (83.1%) of respondents reported working in a full-time capacity (31 or more hours per week), with almost half (40.8%) reporting that they work more than 40 hours per week. The respondents indicated working in a variety of capacities and spending an average of 53.82% of their time working in Direct Case Management. In addition, the respondents reported working in several practice settings, with Hospital-based facility being the most commonly cited (44.0%). Almost three-quarters (74.7%) of the respondents reported working in local service area. A detailed description of the survey respondents can be found in Appendix D. Practice Descriptions Means for the scale ratings of the 61 performance tasks, or work activities, were presented in Appendix C along with the average computed value of Risk. The performance tasks are also presented in Appendix E in the order of Risk. The reliability of the scales was assessed to determine how consistently the measures contributed to the weights of the tasks and domains. Imagine a scale that registers a substantially different weight with each use for the same person. With this inconsistency (i.e., unreliability), it would be difficult to determine an accurate weight. This analogy can be extended to the Consequence, Frequency, and Performance Expectation ratings. It is important to understand the consistency of the data along these dimensions in order to draw defensible conclusions. Reliability was measured by the intraclass correlation that measures internal consistency (i.e., Cronbach s alpha) using the respondents ratings of Consequence, Frequency, and Performance Expectation. This measure indicates the extent to which each task rating consistently measures what other tasks measure. Reliability coefficients range from 0 to 1. Adequate reliability ratings are above 0.7. Reliability values below 0.7 indicate an excessive amount of measurement error. The reliability of the Consequence, Frequency, and Performance Expectation ratings were 0.989, 0.965, and 0.966, respectively. These values easily exceeded the critical value of Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 8

0.7, indicating that the measurement error is sufficiently small to use these ratings in the computation of the domain and task weights in addition to the computation of Risk for each task statement. Table 2 presents the 20 highest ranking task statements. Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 9

Table 2. The 20 task statements with the highest values of initial Risk Domain and Task Performance Expectation Consequence Frequency Domain Task Statement N Median Mean Std N Median Mean Std N Median Mean Std Initial Final Risk Risk Weight 1 1 Screens clients or populations for health needs 275 3 2.92 0.31 277 4 3.96 1.23 277 5 4.87 0.49 19.25 19.25 0.03 1 2 Identifies potential clients for case management 293 3 2.87 0.37 292 3 3.35 1.14 290 5 4.66 0.60 15.62 15.62 0.02 services 1 3 Verifies the client s assignment for case 293 3 2.88 0.33 293 3 3.09 1.15 293 5 4.69 0.54 14.47 14.47 0.02 management services is consistent with regulatory, accreditation, and jurisdictional guidelines 1 4 Obtains client consent for case management 277 3 2.83 0.41 279 3 3.32 1.08 280 4 4.33 0.78 14.34 14.34 0.02 service 1 5 Performs the client s biopsychosocial assessment 274 3 2.90 0.34 275 3 3.23 1.07 277 5 4.43 0.76 14.29 14.29 0.02 1 6 Verifies the client s medication reconciliation is 295 3 2.65 0.71 288 4 3.47 1.38 291 5 4.02 1.33 13.95 13.95 0.02 completed 1 7 Assesses the client s health literacy 282 3 2.85 0.39 282 3 3.22 1.09 283 5 4.31 0.84 13.91 13.91 0.02 1 8 Identifies the client s needs, goals, and current 275 3 2.87 0.40 274 3 3.15 1.14 275 5 4.37 0.85 13.76 13.76 0.02 services 1 9 Identifies the client s payor sources and coverage 277 3 2.84 0.42 275 3 3.12 1.11 275 5 4.36 0.85 13.58 13.58 0.02 1 10 Identifies the client s risk factors and barriers to 278 3 2.88 0.39 279 3 2.93 1.14 280 5 4.59 0.77 13.46 13.46 0.02 care or recovery 1 11 Identifies populations risk factors (e.g., obesity, 295 3 2.86 0.41 293 3 3.09 1.20 293 5 4.35 0.84 13.45 13.45 0.02 sickle cell trait, COPD) 1 12 Identify the client s level of care based on 285 3 2.84 0.39 285 3 2.98 1.14 286 5 4.51 0.72 13.43 13.43 0.02 utilization review criteria 2 13 Engages the client in the development of a case 286 3 2.83 0.41 285 3 2.93 1.02 286 5 4.57 0.68 13.38 13.38 0.02 management plan 2 14 Develops a client-focused case management plan 272 3 2.83 0.42 274 3 3.01 1.02 275 5 4.39 0.83 13.20 13.20 0.02 (e.g., support systems, levels of care, medical necessity) 2 15 Develops client-focused outcome measures 274 3 2.88 0.37 275 3 3.00 1.07 274 5 4.38 0.80 13.13 13.13 0.02 2 16 Identifies available resources to meet established 284 3 2.87 0.36 283 3 2.97 1.08 283 5 4.39 0.77 13.05 13.05 0.02 goals included in the case management plan 2 17 Validates case management plan is consistent with evidence-based practice, regulatory, accreditation, and jurisdictional guidelines 283 3 2.80 0.45 285 3 2.92 1.16 285 5 4.42 0.83 12.88 12.88 0.02 Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 10

Domain and Task Performance Expectation Consequence Frequency Domain Task Statement N Median Mean Std N Median Mean Std N Median Mean Std Initial Final Risk Risk Weight 2 18 Collaborates with stakeholders (e.g., clients, 283 3 2.80 0.42 280 3 2.85 1.08 284 5 4.52 0.66 12.86 12.86 0.02 employers, payors, providers, support system) 2 19 Communicates the case management plan to 274 3 2.80 0.45 273 3 3.02 1.09 273 4 4.22 0.85 12.76 12.76 0.02 stakeholders (e.g., clients, employers, payors, providers, support system) 3 20 Negotiates with clients, payors, and providers for services 280 3 2.80 0.43 280 3 3.02 1.06 280 4 4.22 0.84 12.75 12.75 0.02 Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 11

Table 3. The 20 task statements with the lowest values of initial Risk Domain and Task Performance Expectation Consequence Frequency Domain Task Statement N Median Mean Std N Median Mean Std N Median Mean Std Initial Final Risk Risk Weight 7 59 Performs on-going program evaluation for 275 2 2.15 0.74 269 2 1.99 0.97 272 3 2.94 1.29 5.83 0.00 0.00 quality and cost-effectiveness 7 61 Identify needs for client-centered changes in 276 2 2.15 0.72 270 2 2.19 1.10 272 3 2.83 1.28 6.20 0.00 0.00 organizational and governmental policy 7 58 Analyzes data for variances and quality indicator 275 2 2.09 0.75 267 2 2.15 1.06 270 3 2.92 1.35 6.29 6.29 0.01 and core measures 7 60 Identify needs for the expansion or 274 2 2.20 0.69 269 2 2.17 1.09 272 3 2.96 1.26 6.43 0.00 0.00 establishment of services within the organization 7 57 Collects data for variances and quality indicators 276 2 2.29 0.69 272 2 2.06 0.99 273 3 3.22 1.21 6.62 6.62 0.01 and core measures 7 56 Analyzes client outcomes using national 277 2 2.19 0.75 270 2 2.25 1.13 275 3 3.07 1.36 6.91 6.91 0.01 standards 7 55 Develops client-specific, program-focused 276 2 2.25 0.74 271 2 2.17 1.08 273 3 3.20 1.29 6.95 6.95 0.01 outcome measures 7 54 Analyzes aggregate data for utilization 276 2 2.31 0.73 271 2 2.17 1.03 273 3 3.21 1.29 6.97 6.97 0.01 7 53 Collects aggregate data for tracking and 275 2 2.33 0.74 268 2 2.43 1.14 273 3 3.23 1.33 7.83 7.83 0.01 outcomes management 6 52 Conducts cost-benefit analysis 276 3 2.45 0.67 273 2 2.44 1.09 275 4 3.44 1.23 8.37 8.37 0.01 6 51 Evaluate the effectiveness of the case 278 3 2.44 0.70 272 3 2.66 1.17 275 3 3.22 1.21 8.55 8.55 0.01 management plan 6 50 Evaluates the client s progress toward goals 278 3 2.72 0.61 278 2 2.45 1.17 276 4 3.68 1.26 9.03 9.03 0.01 6 49 Evaluates the client s knowledge of the 279 3 2.65 0.65 276 2 2.55 1.11 278 4 3.74 1.21 9.55 9.55 0.01 treatment plan 6 48 Evaluates the client s knowledge of the 278 3 2.65 0.62 276 3 2.57 1.12 278 4 3.81 1.14 9.79 9.79 0.01 education provided 5 47 Facilitates the resolution of ethical conflict 275 3 2.76 0.50 278 3 2.56 1.03 278 4 3.86 1.03 9.87 9.87 0.01 5 46 Maintains the client s confidentiality 282 3 2.57 0.65 282 3 2.69 1.12 284 4 3.78 1.17 10.16 10.16 0.01 5 45 Clarifies the client s goals to stakeholders (e.g., employers, payors, providers, support system) 5 44 Communicates client care preferences to stakeholders (e.g., employers, payors, providers, support system) 275 3 2.78 0.49 272 3 2.64 1.04 275 4 3.98 1.00 10.53 10.53 0.02 278 3 2.8 0.47 276 3 2.64 1.02 277 4 4.13 0.87 10.90 10.90 0.02 Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 12

Domain and Task Performance Expectation Consequence Frequency Domain Task Statement N Median Mean Std N Median Mean Std N Median Mean Std Initial Final Risk Risk Weight 5 43 Promotes care that minimizes delays and 279 3 2.87 0.37 278 2 2.46 1.13 278 5 4.46 0.77 11.00 11.00 0.02 variances in the delivery of quality care 5 42 Promotes the client s self-advocacy in order to maintain or achieve autonomy 277 3 2.79 0.46 277 3 2.76 1.1 279 4 4.02 0.98 11.11 11.11 0.02 Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 13

In these above two tables and Appendix E, the task statements are sorted by the values of Initial Risk, those being the values computed from the survey data. The rightmost columns indicate Final Risk, which is zero in those instances where the panel removed the task statement from further consideration because of low values of Performance Expectation. The panel removed some task statements from further consideration on the role delineation because the survey data indicated the task was performed outside the period of six months after certification. These removed tasks are presented in domain and task order in Table 4. Table 4. Tasks removed after panel consideration of Performance Expectation Domain Task Statement 7 59 Performs on-going program evaluation for quality and cost-effectiveness 7 60 Identify needs for the expansion or establishment of services within the organization 7 61 Identify needs for client-centered changes in organizational and governmental policy Copyright 2013 American Nurses Credentialing Center, All Rights Reserved 14

Domains and Tasks I. Assessment 1. Screens clients or populations for health needs 2. Identifies potential clients for case management services 3. Verifies the client s assignment for case management services is consistent with regulatory, accreditation, and jurisdictional guidelines 4. Obtains client consent for case management service 5. Performs the client s biopsychosocial assessment 6. Verifies the client s medication reconciliation is completed 7. Assesses the client s health literacy 8. Identifies the client s needs, goals, and current services 9. Identifies the client s payor sources and coverage 10. Identifies the client s risk factors and barriers to care or recovery 11. Identifies populations risk factors (e.g., obesity, sickle cell trait, COPD) 12. Identify the client s level of care based on utilization review criteria II: Planning and Collaboration 13. Engages the client in the development of a case management plan 14. Develops a client-focused case management plan (e.g., support systems, levels of care, medical necessity) 15. Develops client-focused outcome measures 16. Identifies available resources to meet established goals included in the case management plan 17. Validates case management plan is consistent with evidence-based practice, regulatory, accreditation, and jurisdictional guidelines 18. Collaborates with stakeholders (e.g., clients, employers, payors, providers, support system) 19. Communicates the case management plan to stakeholders (e.g., clients, employers, payors, providers, support system) III: Implementation, Coordination, and Linking 20. Negotiates with clients, payors, and providers for services 21. Links the client to services and resources to meet established goals included in the case management plan 22. Refers the client for complex case management or disease management based on the client s needs and established criteria 23. Facilitates the client s transition to the next level of care 24. Facilitates communication, problem-solving, and conflict resolution with stakeholders (e.g., clients, employers, payors, providers, support system) 25. Coordinates case management interventions with stakeholders (e.g., clients, employers, payors, providers, support system) 26. Implements interventions to address the client s barriers to care and recovery 27. Documents the case management process (e.g., assessment, plan, on-going interventions, outcomes) 28. Assists in the denial and appeal process 29. Modifies the case management plan based on the client outcomes IV: Education 30. Educates the client regarding the case management process 31. Educates the client regarding the identified disease process 32. Educates the client regarding health, wellness, and disease prevention 33. Educates the client regarding treatment options and resources 34. Educates the client regarding self-management strategies 35. Educates the client regarding benefit coverage 36. Educates the client regarding anticipated outcomes 37. Educates the client regarding transitions across continuum of care 38. Educates the client regarding the patient s bill of rights 39. Educates members of health care team regarding client-specific issues (e.g., cultural beliefs, outcomes of biopsychosocial assessment, payor benefits) 40. Educates the payor regarding the client s case management plan V: Advocacy Appendix A Domains and Tasks Copyright 2013 American Nurses Credentialing Center, All Rights Reserved A-2

Domains and Tasks 41. Promotes access to the continuum of care in order to minimize disparities (e.g., economic, ethnic, linguistic, racial, social) 42. Promotes the client s self-advocacy in order to maintain or achieve autonomy 43. Promotes care that minimizes delays and variances in the delivery of quality care 44. Communicates client care preferences to stakeholders (e.g., employers, payors, providers, support system) 45. Clarifies the client s goals to stakeholders (e.g., employers, payors, providers, support system) 46. Maintains the client s confidentiality 47. Facilitates the resolution of ethical conflict VI: Evaluation 48. Evaluates the client s knowledge of the education provided 49. Evaluates the client s knowledge of the treatment plan 50. Evaluates the client s progress toward goals 51. Evaluate the effectiveness of the case management plan 52. Conducts cost-benefit analysis VII: Systems 53. Collects aggregate data for tracking and outcomes management 54. Analyzes aggregate data for utilization 55. Develops client-specific, program-focused outcome measures 56. Analyzes client outcomes using national standards 57. Collects data for variances and quality indicators and core measures 58. Analyzes data for variances and quality indicator and core measures 59. Performs on-going program evaluation for quality and cost-effectiveness 60. Identify needs for the expansion or establishment of services within the organization 61. Identify needs for client-centered changes in organizational and governmental policy Appendix A Domains and Tasks Copyright 2013 American Nurses Credentialing Center, All Rights Reserved A-3

What is your gender? Female Male What is your race? African American American Indian Asian Hispanic White Mixed Other (Enter other in a text box) What is the highest degree in nursing you have been awarded? Diploma Associate degree Bachelor s degree Master s degree Doctor of Nursing Practice Doctorate degree [DSN, DNSc, PhD] Other (Enter other in a text box) Do you have a degree outside of nursing? Yes No If yes, what is the highest degree outside of nursing you have been awarded? Diploma Associate s Bachelor s Master s Doctorate Other None Are you currently working in nursing case management? Yes No Do you hold other case management certifications? Yes No Appendix B Demographic Variables Copyright 2013 American Nurses Credentialing Center, All Rights Reserved B-2

If yes, which of the following other certifications do you hold? (Select all that apply.) Certified Professional in Healthcare Quality [CPHQ] Certified Case Manager [CCM] Accredited Case Manager [ACM] Managed Healthcare Professional [MHP] Certified Rehabilitation Registered Nurse [CRRN] Certified Clinical Documentation Specialist [CCDS] Certified Managed Care Nurse [CMCN] Certified Nurse Life Care Planner [CNLCP] Certified Professional in Utilization Review [CPUR] Fellowship in the Academy of Case Management Case Management Administrator Certification [CMAC] Certified Geriatric Care Manager [CGCM] Other (Enter others in a text box) What is your age group? Less than 20 years 20 to 29 years 30 to 39 years 40 to 49 years 50 to 59 years 60 to 69 years More than 69 years How many years have you been practicing as an RN? How many years have you worked in nursing case management? How many years have you been certified in nursing case management? How many hours per week do you spend practicing in nursing case management? 0 to 10 11 to 20 21 to 30 31 to 40 More than 40 What percent of your work time is spent in the following area? (Values must add to 100%) Assessment Planning and Collaboration Implementation, Coordination, and Linking Education Advocacy Evaluation Systems Other Appendix B Demographic Variables Copyright 2013 American Nurses Credentialing Center, All Rights Reserved B-3

Which best describes your primary practice setting? Ambulatory care (e.g., clinic, physician s office, urgent care) Assisted living/skilled nursing Case management company Community-based Group home/residential facility Health plan and/or insurance company Home health Hospice Hospital-based facility (e.g., acute inpatient, emergency department) Independent practice Outpatient Other (Enter other in a text box) In which work service area do you PRIMARILY practice? Local service area Regional [multi-state] service area National service area International service area Appendix B Demographic Variables Copyright 2013 American Nurses Credentialing Center, All Rights Reserved B-4

Summary Table Performance Expectation Consequence Frequency Initial Final Domain Task N Median Mean Std N Median Mean Std N Median Mean Std Risk Risk Weight 1 1. Screens clients or populations for health needs 294 3 2.84 0.43 293 3 2.82 1.10 296 5 4.51 0.78 12.71 12.71 0.02 2. Identifies potential clients for case management 295 3 2.83 0.42 295 3 2.61 1.04 294 5 4.43 0.81 11.54 11.54 0.02 services 3. Verifies the client s assignment for case 294 3 2.71 0.54 293 3 2.71 1.18 293 4 4.19 0.97 11.37 11.37 0.02 management services is consistent with regulatory, accreditation, and jurisdictional guidelines 4. Obtains client consent for case management service 296 3 2.79 0.54 295 3 2.73 1.32 296 5 4.43 1.03 12.10 12.10 0.02 5. Performs the client s biopsychosocial assessment 294 3 2.75 0.56 293 3 2.88 1.20 294 5 4.29 1.06 12.36 12.36 0.02 6. Verifies the client s medication reconciliation is 295 3 2.65 0.71 288 4 3.47 1.38 291 5 4.02 1.33 13.95 13.95 0.02 completed 7. Assesses the client s health literacy 295 3 2.86 0.41 293 3 3.09 1.20 293 5 4.35 0.84 13.45 13.45 0.02 8. Identifies the client s needs, goals, and current 293 3 2.88 0.33 293 3 3.09 1.15 293 5 4.69 0.54 14.47 14.47 0.02 services 9. Identifies the client s payor sources and coverage 293 3 2.82 0.47 290 3 2.77 1.15 290 5 4.45 0.91 12.32 12.32 0.02 10. Identifies the client s risk factors and barriers to care 293 3 2.87 0.37 292 3 3.35 1.14 290 5 4.66 0.60 15.62 15.62 0.02 or recovery 11. Identifies populations risk factors (e.g., obesity, 289 3 2.75 0.48 286 3 2.91 1.15 289 4 4.21 0.94 12.23 12.23 0.02 sickle cell trait, COPD) 12. Identify the client s level of care based on utilization 294 3 2.70 0.52 290 3 2.69 1.08 292 4.5 4.22 0.98 11.37 11.37 0.02 review criteria 2 13. Engages the client in the development of a case 284 3 2.86 0.38 284 3 2.74 1.01 285 5 4.54 0.68 12.41 12.41 0.02 management plan 14. Develops a client-focused case management plan 286 3 2.83 0.41 285 3 2.93 1.02 286 5 4.57 0.68 13.38 13.38 0.02 (e.g., support systems, levels of care, medical necessity) 15. Develops client-focused outcome measures 286 3 2.73 0.52 282 3 2.73 1.02 286 4 4.24 0.95 11.57 11.57 0.02 16. Identifies available resources to meet established 283 3 2.80 0.42 280 3 2.85 1.08 284 5 4.52 0.66 12.86 12.86 0.02 goals included in the case management plan 17. Validates case management plan is consistent with 282 3 2.69 0.51 280 3 2.94 1.15 284 4 4.23 0.90 12.43 12.43 0.02 evidence-based practice, regulatory, accreditation, and jurisdictional guidelines 18. Collaborates with stakeholders (e.g., clients, employers, payors, providers, support system) 285 3 2.84 0.39 285 3 2.98 1.14 286 5 4.51 0.72 13.43 13.43 0.02 Performance expectation response options: 1 = Not at all, 2 = After the first 6 months, 3 = Within the first 6 months Consequence response options: 1 = No harm, 2 = Minimal harm, 3 = Moderate harm, 4 = Substantial harm, 5 = Extreme harm Frequency response options: 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Repeatedly Appendix C Summary Table Copyright 2013 American Nurses Credentialing Center, All Rights Reserved C-2

Summary Table Performance Expectation Consequence Frequency Initial Final Domain Task N Median Mean Std N Median Mean Std N Median Mean Std Risk Risk Weight 19. Communicates the case management plan to 283 3 2.80 0.45 285 3 2.92 1.16 285 5 4.42 0.83 12.88 12.88 0.02 stakeholders (e.g., clients, employers, payors, providers, support system) 3 20. Negotiates with clients, payors, and providers for 282 3 2.57 0.65 282 3 2.69 1.12 284 4 3.78 1.17 10.16 10.16 0.01 services 21. Links the client to services and resources to meet 284 3 2.87 0.36 283 3 2.97 1.08 283 5 4.39 0.77 13.05 13.05 0.02 established goals included in the case management plan 22. Refers the client for complex case management or 281 3 2.78 0.47 282 3 3.13 1.09 282 4 3.93 0.94 12.31 12.31 0.02 disease management based on the client s needs and established criteria 23. Facilitates the client s transition to the next level of 282 3 2.85 0.39 282 3 3.22 1.09 283 5 4.31 0.84 13.91 13.91 0.02 care 24. Facilitates communication, problem-solving, and 284 3 2.73 0.49 283 3 2.97 1.07 280 4 4.17 0.93 12.38 12.38 0.02 conflict resolution with stakeholders (e.g., clients, employers, payors, providers, support system) 25. Coordinates case management interventions with 276 3 2.77 0.48 275 3 2.92 1.03 275 4 4.21 0.90 12.27 12.27 0.02 stakeholders (e.g., clients, employers, payors, providers, support system) 26. Implements interventions to address the client s 277 3 2.83 0.41 279 3 3.32 1.08 280 4 4.33 0.78 14.34 14.34 0.02 barriers to care and recovery 27. Documents the case management process (e.g., 278 3 2.88 0.39 279 3 2.93 1.14 280 5 4.59 0.77 13.46 13.46 0.02 assessment, plan, on-going interventions, outcomes) 28. Assists in the denial and appeal process 278 3 2.44 0.70 272 3 2.66 1.17 275 3 3.22 1.21 8.55 8.55 0.01 29. Modifies the case management plan based on the 280 3 2.80 0.43 280 3 3.02 1.06 280 4 4.22 0.84 12.75 12.75 0.02 client outcomes 4 30. Educates the client regarding the case management 279 3 2.87 0.37 278 2 2.46 1.13 278 5 4.46 0.77 11.00 11.00 0.02 process 31. Educates the client regarding the identified disease 279 3 2.83 0.46 277 3 3.01 1.16 278 4 4.21 0.97 12.65 12.65 0.02 process 32. Educates the client regarding health, wellness, and 273 3 2.81 0.45 273 3 2.90 1.12 275 4 4.19 0.95 12.14 12.14 0.02 disease prevention 33. Educates the client regarding treatment options and 274 3 2.80 0.45 273 3 3.02 1.09 273 4 4.22 0.85 12.76 12.76 0.02 resources 34. Educates the client regarding self-management strategies 273 3 2.82 0.44 272 3 2.96 1.10 274 4 4.19 0.92 12.40 12.40 0.02 Performance expectation response options: 1 = Not at all, 2 = After the first 6 months, 3 = Within the first 6 months Consequence response options: 1 = No harm, 2 = Minimal harm, 3 = Moderate harm, 4 = Substantial harm, 5 = Extreme harm Frequency response options: 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Repeatedly Appendix C Summary Table Copyright 2013 American Nurses Credentialing Center, All Rights Reserved C-3

Summary Table Performance Expectation Consequence Frequency Initial Final Domain Task N Median Mean Std N Median Mean Std N Median Mean Std Risk Risk Weight 35. Educates the client regarding benefit coverage 278 3 2.65 0.62 276 3 2.57 1.12 278 4 3.81 1.14 9.79 9.79 0.01 36. Educates the client regarding anticipated outcomes 278 3 2.80 0.47 276 3 2.64 1.02 277 4 4.13 0.87 10.90 10.90 0.02 37. Educates the client regarding transitions across 279 3 2.80 0.45 276 3 2.67 1.07 276 4 4.17 0.87 11.14 11.14 0.02 continuum of care 38. Educates the client regarding the patient s bill of 278 3 2.72 0.61 278 2 2.45 1.17 276 4 3.68 1.26 9.03 9.03 0.01 rights 39. Educates members of health care team regarding 277 3 2.79 0.46 277 3 2.76 1.10 279 4 4.02 0.98 11.11 11.11 0.02 client-specific issues (e.g., cultural beliefs, outcomes of biopsychosocial assessment, payor benefits) 40. Educates the payor regarding the client s case 279 3 2.65 0.65 276 2 2.55 1.11 278 4 3.74 1.21 9.55 9.55 0.01 management plan 5 41. Promotes access to the continuum of care in order 274 3 2.75 0.50 275 3 2.88 1.09 275 4 3.99 0.96 11.47 11.47 0.02 to minimize disparities (e.g., economic, ethnic, linguistic, racial, social) 42. Promotes the client s self-advocacy in order to 275 3 2.81 0.43 272 3 2.74 1.05 276 4 4.21 0.86 11.54 11.54 0.02 maintain or achieve autonomy 43. Promotes care that minimizes delays and variances 277 3 2.84 0.42 275 3 3.12 1.11 275 5 4.36 0.85 13.58 13.58 0.02 in the delivery of quality care 44. Communicates client care preferences to 275 3 2.78 0.49 272 3 2.64 1.04 275 4 3.98 1.00 10.53 10.53 0.02 stakeholders (e.g., employers, payors, providers, support system) 45. Clarifies the client s goals to stakeholders (e.g., 275 3 2.76 0.50 278 3 2.56 1.03 278 4 3.86 1.03 9.87 9.87 0.01 employers, payors, providers, support system) 46. Maintains the client s confidentiality 275 3 2.92 0.31 277 4 3.96 1.23 277 5 4.87 0.49 19.25 19.25 0.03 47. Facilitates the resolution of ethical conflict 278 3 2.69 0.53 275 4 3.38 1.23 277 4 3.69 1.14 12.45 12.45 0.02 6 48. Evaluates the client s knowledge of the education 275 3 2.87 0.40 274 3 3.15 1.14 275 5 4.37 0.85 13.76 13.76 0.02 provided 49. Evaluates the client s knowledge of the treatment 274 3 2.90 0.34 275 3 3.23 1.07 277 5 4.43 0.76 14.29 14.29 0.02 plan 50. Evaluates the client s progress toward goals 274 3 2.88 0.37 275 3 3.00 1.07 274 5 4.38 0.80 13.13 13.13 0.02 51. Evaluate the effectiveness of the case management 272 3 2.83 0.42 274 3 3.01 1.02 275 5 4.39 0.83 13.20 13.20 0.02 plan 52. Conducts cost-benefit analysis 275 2 2.33 0.74 268 2 2.43 1.14 273 3 3.23 1.33 7.83 7.83 0.01 Performance expectation response options: 1 = Not at all, 2 = After the first 6 months, 3 = Within the first 6 months Consequence response options: 1 = No harm, 2 = Minimal harm, 3 = Moderate harm, 4 = Substantial harm, 5 = Extreme harm Frequency response options: 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Repeatedly Appendix C Summary Table Copyright 2013 American Nurses Credentialing Center, All Rights Reserved C-4

Summary Table Performance Expectation Consequence Frequency Initial Final Domain Task N Median Mean Std N Median Mean Std N Median Mean Std Risk Risk Weight 7 53. Collects aggregate data for tracking and outcomes 276 2 2.29 0.69 272 2 2.06 0.99 273 3 3.22 1.21 6.62 6.62 0.01 management 54. Analyzes aggregate data for utilization 275 2 2.15 0.74 269 2 1.99 0.97 272 3 2.94 1.29 5.83 0.00 0.00 55. Develops client-specific, program-focused outcome 276 3 2.45 0.67 273 2 2.44 1.09 275 4 3.44 1.23 8.37 8.37 0.01 measures 56. Analyzes client outcomes using national standards 276 2 2.25 0.74 271 2 2.17 1.08 273 3 3.20 1.29 6.95 6.95 0.01 57. Collects data for variances and quality indicators 276 2 2.31 0.73 271 2 2.17 1.03 273 3 3.21 1.29 6.97 6.97 0.01 and core measures 58. Analyzes data for variances and quality indicator 275 2 2.09 0.75 267 2 2.15 1.06 270 3 2.92 1.35 6.29 6.29 0.01 and core measures 59. Performs on-going program evaluation for quality 277 2 2.19 0.75 270 2 2.25 1.13 275 3 3.07 1.36 6.91 6.91 0.01 and cost-effectiveness 60. Identify needs for the expansion or establishment of 274 2 2.20 0.69 269 2 2.17 1.09 272 3 2.96 1.26 6.43 0.00 0.00 services within the organization 61. Identify needs for client-centered changes in organizational and governmental policy 276 2 2.15 0.72 270 2 2.19 1.10 272 3 2.83 1.28 6.20 0.00 0.00 Performance expectation response options: 1 = Not at all, 2 = After the first 6 months, 3 = Within the first 6 months Consequence response options: 1 = No harm, 2 = Minimal harm, 3 = Moderate harm, 4 = Substantial harm, 5 = Extreme harm Frequency response options: 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Repeatedly Appendix C Summary Table Copyright 2013 American Nurses Credentialing Center, All Rights Reserved C-5

Characteristics of the survey respondents Survey respondents were asked to provide information on different demographic variables. The following tables provide the demographic breakdown of the survey respondents. Table 1. What is your gender? Count Percent Female 266 96.7 Male 9 3.3 Total 275 100.0 Missing 60 Table 2. What is your race/ethnicity? Count Percent Black or African American 24 8.7 American Indian or Alaska Native 1 0.4 Asian 11 4.0 Native Hawaiian or Other Pacific Islander 2 0.7 Hispanic / Latino of any race 7 2.5 White 221 79.8 Two or more races 9 3.2 Other (please specify) 2 0.7 Total 277 100.0 Missing 58 Other (please specify) White race, partial Latin ethnicity (half) european american Appendix D Characteristics of Survey Respondents Copyright 2013 American Nurses Credentialing Center, All Rights Reserved D-2

Table 3. What is the highest degree in nursing you have been awarded? Count Percent Diploma 19 6.8 Associate degree 51 18.3 Bachelor s degree 142 51.1 Master s degree 61 21.9 Doctor of Nursing Practice 1 0.4 Doctorate degree [DSN, DNSc, PhD] 0 0.0 Other (please specify) 4 1.4 Total 278 99.9* Missing 57 *Percent sum equals 99.9 due to rounding Other (please specify) RN-BC, CCM, CMCN Case management & orthopedic certification Bachelor's in Education, BSN, Certified CM Juris Doctorate/Nurse Attorney Table 4. Do you have a degree outside of nursing? Count Percent Yes 68 24.6 No 208 75.4 Total 276 100.0 Missing 59 Table 5. If you answered "Yes" to question 4 above, what is the highest degree outside of nursing you have been awarded? Count Percent Diploma 0 0.0 Associate 17 22.1 Bachelor s 34 44.2 Master s 24 31.2 Doctorate 1 1.3 Other (please specify) 1 1.3 Total 77 100.1* Missing 258 *Percent sum equals 100.1 due to rounding Appendix D Characteristics of Survey Respondents Copyright 2013 American Nurses Credentialing Center, All Rights Reserved D-3

Table 6. Do you hold other case management certifications? Count Percent Yes 116 42.0 No 160 58.0 Total 276 100.0 Missing 59 Table 7. If you answered "Yes" to question 6 above, which of the following other certifications do you hold? (Select all that apply.) Count Percent Certified Professional in Healthcare Quality [CPHQ] 3 2.5 Certified Case Manager [CCM] 106 87.6 Accredited Case Manager [ACM] 9 7.4 Managed Healthcare Professional [MHP] 0 0.0 Certified Rehabilitation Registered Nurse [CRRN] 6 5.0 Certified Clinical Documentation Specialist [CCDS] 0 0.0 Certified Managed Care Nurse [CMCN] 4 3.3 Certified Nurse Life Care Planner [CNLCP] 7 5.8 Certified Professional in Utilization Review [CPUR] 3 2.5 Fellowship in the Academy of Case Management 0 0.0 Case Management Administrator Certification [CMAC] 0 0.0 Certified Geriatric Care Manager [CGCM] 1 0.8 Other (please specify) 29 24.0 Answered question 121 Skipped question 214 Other (please specify) AIDS Certified Registered Nurse via ANAC Ambulatory Care ANCC ANCC ANCC Board Certification in Nursing Case Management BC-CM Board Certification Board Certification in Case Management Board Certified in CM Board Certified in Nurse Case Management Certified Care Manager certified diabetes educator Certified Nurse Case Manager (RN-BC) Certified Professional in Healthcare Management Certified Psychiatric/Mental Health Nurse, RN-BC Chronic Care Professional CNS CPHM - which replaced CPUR Legal Nurse Consultant LNCC LNCP-C Appendix D Characteristics of Survey Respondents Copyright 2013 American Nurses Credentialing Center, All Rights Reserved D-4

Other (please specify) Medical-Surgical Nursing Nursing professional development and CNS Community & Public Health Psychiatric and mental health RCP/RRT RN-BC RN-BC RN-BC Board Certified Nurse Case Manager RN-BC, CM Table 8. What is your age group? Count Percent Less than 20 years 0 0.0 20 to 29 years 2 0.7 30 to 39 years 22 7.9 40 to 49 years 69 24.9 50 to 59 years 132 47.7 60 to 69 years 52 18.8 More than 69 years 0 0.0 Total 277 100.0 Missing 58 Table 9. How many years have you been practicing as an RN? Statistic Value N 276 Minimum 6 Maximum 48 Median 26 Mean 25.39 StDev 9.37 Table 10. How many years have you worked in nursing case management? Statistic Value N 269 Minimum 1.5 Maximum 36 Median 10 Mean 11.46 StDev 6.60 Appendix D Characteristics of Survey Respondents Copyright 2013 American Nurses Credentialing Center, All Rights Reserved D-5

Table 11. How many years have you been certified in nursing case management? Statistic Value N 271 Minimum 0 Maximum 28 Median 2 Mean 4.58 StDev 5.48 Table 12. How many hours per week do you spend practicing in nurse case management? Count Percent 0 to 10 11 4.0 11 to 20 14 5.1 21 to 30 21 7.7 31 to 40 115 42.3 More than 40 111 40.8 Total 272 99.9* Missing 63 *Percent sum equals 99.9 due to rounding. Table 13. What percent of your work time is spent in the following areas? (Please enter whole numbers only. Values must add to 100%.) Average Percent Response Total Response Count Administrative tasks 17.55 4,018 229 Management 17.38 3,563 205 Direct case management 53.82 13,832 257 Direct clinical care 8.96 1,550 173 Professional development 6.93 1,359 196 Research 3.62 593 164 Quality management 7.95 1,510 190 Other 10.05 1,075 107 Answered question 275 Skipped question 60 Appendix D Characteristics of Survey Respondents Copyright 2013 American Nurses Credentialing Center, All Rights Reserved D-6

Table 14. Which best describes your primary practice? Count Percent Ambulatory care (e.g., clinic, physician s office, urgent care) 26 9.4 Assisted living/skilled nursing 0 0.0 Case management company 24 8.7 Community-based 15 5.4 Group home/residential facility 0 0.0 Health plan and/or insurance company 29 10.5 Home health 5 1.8 Hospice 1 0.4 Hospital-based facility (e.g., acute inpatient, emergency department) 122 44.0 Independent practice 12 4.3 Outpatient 17 6.1 Other (please specify) 26 9.4 Total 277 100.0 Missing 58 Other (please specify) ACO ACO Ambulatory Care Center consulting County case management Department of defense NAVY Case Management HMO Hospital, telehealth Insurance based Intensive mental health outpatient program, IOP IPA Medical Device Company Military military Military facility Military Health System Military Hospital military treatment facility Military treatment Facility Military Treatment Facility (expanded physician s office) Navy Hospital occupational health telework Veteran's Affairs facility workers comp Wyoming Workers' Compensation Appendix D Characteristics of Survey Respondents Copyright 2013 American Nurses Credentialing Center, All Rights Reserved D-7