Issue Briefs

The role of the professional case manager is changing rapidly.  Health reform has called upon the industry to ensure that care delivered is efficient, effective, high quality and low cost.  Never in our history has the role and the function of the professional case manager been more important.  The expectations of today’s case manager are evolving and the experts in policy, research and industry are talking with the Commission about changes affecting case management practice.

The Commission’s Issue Briefs are offered as part of the CMLearning Network®. Each publication covers topics that are timely and relevant for today’s professional case manager. If you would you like a hard copy of an Issue Brief for your staff, or for use at a meeting, we can send you a limited amount at no charge. Simply make your request by clicking here, and we'll be happy to send them to you

            Professionals adhere to codes of ethics.  For case managers, it's the Code of Professional Conduct for
            Case Managers.  Developed by and for professional case managers, it provides ethical guidelines and
            principles.  It serves as a baseline expectation, regardless of the care setting.  

Words matter. Change the way you ask a question and transform your relationship with a client. Professional case managers understand this, and it’s at the heart of successfully addressing the impact of trauma.

Increasingly, social workers are seeking board certification as case managers. Along with that interest come questions—about eligibility, career trajectory, exam costs, benefits and a host of other issues.

For all the changes we’ve witnessed in health care delivery, health care is still typically sickness care, focused on the immediate presenting problem, the episode, the diagnosis. Even case managers, trained to take the long view, succumb to the tyranny of the urgent. “What we know, however, is that as case managers, we must constantly move the focus back to the big picture: to transitions of care across the continuum, to alignment of the different pieces of health care,” says Patrice Sminkey, CEO of the Commission for Case Manager Certification. “No matter how much we accomplish, we must keep moving forward.”

"Nobody wants to wake up and face the world as an addict,” says Robert LoNigro, MD, MS. But millions do, and substance abuse disorders (SUDs) remain severely undertreated, explains LoNigro, senior vice president and chief clinical officer at Envolve PeopleCare, part of the Centene Corporation. One recent study found that only about 5 percent of adults who misused prescription opioids in the past year, and just 17 percent of those with prescription opioid addiction, ever receive treatment.

Case managers are consummate team players, working with everyone from patients to their support systems, from physicians to nurses, social workers and pharmacists, from coders to administrators, all on the behalf of patients, to ensure patient-centered care. Taking on this role in the hospital setting can be challenging, but Dartmouth-Hitchcock Medical Center (DHMC), based in Lebanon, N. H., shows that it can be done—and how it can be done successfully.

Skin in the game. Patient engagement. Consumer-driven health care. Regardless of what it’s called, over the past decade everyone seemed to be talking about how individuals could be more active in their health. But that’s just not going to happen until patients have the right tools.

We need to talk. That’s the message Patrice Sminkey, CEO of the Commission for Case Manager Certification, is delivering—not only to professional case managers, but to everyone. “We need to talk about end-of-life care.”

Patient-centered care generates considerable conversation and attention-and, some would say, lip service. How do we fully engage patients in their care while ensuring they receive evidence-based therapies? There have been concerns expressed-even grumbled-in some quarters that the two don't align.

Across the health care continuum, the Affordable Care Act has advanced accountability—and accountability requires measurement. Case managers perform. And in an increasingly value-driven system, the important functions they perform create value.

Once upon a time, payers and clinicians often worked at cross purposes. But as delivery and reimbursement models have gradually changed, so has that dynamic. What’s emerging is a collaborative model of patient-centered, accountable care working toward creating a system that offers better care, better population health and lower costs.

Integrated care involves a whole-person, patient-centered approach that engages patients in the full range of physical, psychological and social aspects of care. That does not describe the status quo: Behavioral and physical health operate in their own silos, to the detriment of patients, the health care system and society.

After months of review, research and work, the Commission for Case Manager Certification® has released its revised Code of Professional Conduct for Case Managers. Developed by professionals for professional case managers, it provides ethical guidelines and principles. It’s neither a roadmap nor a rule book: That’s because professional case management requires wisdom, judgment and critical thinking. The Code honors this and continues to resonate with its recent updates.

One of the least discussed but most crucial aspects of health care reform has little to do with buying insurance coverage. A new emphasis on care coordination, care management and care transitions promises to improve care for the most complex and chronically ill patients, as well as deliver more efficient, cost-effective services.  This aspect of health care reform, focused on patient care, relies on functions that are all part of the job of the professional case manager. 

Knowing the questions and answers just isn't enough. It all comes down to real-world applications. That's the lesson Mary Naylor, PhD, RN, learned developing the Transitional Care Model (TCM).

Although the media’s attention to the Affordable Care Act (ACA) has largely centered on the health insurance exchanges, those who have been following the ACA understand considerably more is involved. They know the exchanges account for a relatively small piece of the ACA and its mission to enhance access to quality health care and improve the greater good.

No one questions that care coordination is essential to safe, efficient and effective patient-centered care. What professional case managers have known and practiced for decades is now widely
viewed as an essential function of case management.

What doesn’t kill you makes you stronger. Literally, if we’re talking about medications.  The lack of a continuous and systematic process to ensure medications are taken correctly and are appropriate for the patient kills millions.  The savings in avoidable medical spending with appropriate medication use could pay for over 90 percent of the $325 billion spent in 2012 on medications in the U.S., in addition to saving more than a million lives.  Both the dollars and the lost lives could be mitigated with comprehensive medication management.

As professional case managers continue to take a more prominent role in health care delivery, they frequently encounter situations that require them to balance their responsibility as the patient’s advocate for effective care with other considerations, such as an employer’s financial concerns or a hospital’s need for efficiency. At the same time, they need to understand the appropriate regulatory and legal framework around these sometimes conflicting, frequently confusing, interests.

Expect questions. Lots of them. After more than two months, many consumers—including most of the uninsured—are still confusedabout health insurance exchanges.

 It’s not news that better care coordination and safer care transitions can decrease avoidable readmissions into hospitals. Everyone knows that. What most don’t know is how. One person who does is Amy Boutwell, MD, M.P.P., co-founder of the STAAR (STate Action on Avoidable Rehospitalizations) Initiative of the Institute for Healthcare Improvement (IHI) and senior physician consultant, National Coordinating Center, CMS QIO Care Transitions Theme.

Don’t dare call them “handoffs.”

Guiding patients to the care they need, when they need it, lies at the heart of case management and is critical in the new approaches to care.  The current emphasis on coordinated care has heightened awareness of the need for smoother transitions, while calling attention to the lack thereof.

By now, everybody knows that team-based, coordinated care improves performance in chronic disease management, patient satisfaction and access to care.1  Experts recognize the high-performing   team as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system.2  The challenge becomes ensuring teams are indeed high-performing; that requires more than clinical care. It demands the sort of attention social workers and professional case managers are well equipped to provide as members of fully integrated health care teams.

The rate of health system evolution boggles the mind. New model of care delivery and reimbursement, coupled with changing demographics, are rapidly driving changes designed to fix the current broken system. This dynamic environment demands a robust corps of health care professionals to meet the challenges this inexorable change presents.

Today, case managers must protect the public interest in an increasingly cost-conscious environment. Ethical standards have taken on heightened importance, and the professional case manager needs to know what’s at stake. Read more in this issue brief, featuring Carrie Valiant, Esq., Epstein Becker & Green PC; a member in the Health Care and Life Sciences Practice in the Washington, DC office and co-chair of the firm's health care fraud group, and Susan Jensen, PhD, RN, CCM, MSCC; Owner, ALARIS franchises; Associate Professor, Grand Valley State University; Secretary, the Commission.

If the moral measure of a society is its treatment of its most vulnerable, two models designed to enhance care for the chronically ill have the potential to substantially enhance our moral standing. Without carefully considered case management, however, “For the chronically ill, the health care system is fragmented, discontinuous, difficult to access, inefficient, unsafe and very expensive.” Read more in our issue brief, featuring Chad Boult, MD, MPH, MBA, professor, department of health policy and management at Johns Hopkins Bloomberg School of Public Health, and Janet Tomcavage, RN, MSN, chief clinical transformation officer, Geisinger Insurance Operations.

Case managers possess the expertise to guide clients toward finding their own solutions, to give them the tools to self-manage and to make transformative changes. This truth lies at the heart of motivational interviewing (MI)—collaborative, client-centered conversation that strengthens the client’s own motivation to change. Featuring Catherine M. Mullahy, RN, BS, CRRN, CCM, president, Mullahy & Associates, LLC and Michael G. Goldstein, MD, associate chief consultant for preventive medicine, Veteran's Health Administration (VHA), National Center for Health Promotion and Disease Prevention. Disclaimer: Dr. Goldstein's comments and opinions are his own and do not represent the official views or positions of the Veterans Health Administration.

 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? Featuring Hussein Tahan, DNSc, RN, independent consultant and researcher International Health Care Management & Consulting, New Jersey and knowledge editor, The Commission for Case Manager Certification's CMBOK®, and Patrice Sminkey, RN, chief executive officer, The Commission

  • The Case for Professional Case Management to Enhance Patient-Centered Coordinated Care: A Sampling of the Evidence
    Care coordination is an essential activity to achieve the goals of better individual health, better population health and reduced health care costs. Read the mounting evidence that demonstrates the need for—and success of—professional case management to ensure coordination of care. Multiple examples across various health care settings and throughout the nation are cited of the benefits of professional case management in improving the delivery of health care services for patients.
  • From "turf" to "team" Case Management Interfaces with Team-based Care Models (Volume 2, Issue 3)
    Today’s new models of care—the medical home, advanced primary care and accountable care organizations—are collaborative and connected. Read about the leadership initiative that has transformed the Veteran’s Health Administration into a collaborative, team-based model—including effective use of case managers—in this brief, featuring the VHA’s VACO Primary Care Clinical Program Manager Joanne M. Shear, MS, FNP-BC, and Kathryn M. Serbin, BSN, MS, CCM, of the James A. Lovell Federal Healthcare Facility and the Commission’s chair- elect.
  • Center Stage in the Revolution: A Health Care Reform Action Guide for the Professional Case Manager (Volume 2, Issue 2)
    The Affordable Care Act (ACA) placed case management functions center stage in proposed new models of care. The Commission and its certificants must be part of designing these new models, not merely react to changes after they happen. Learn about today’s key initiatives and how case managers are leveraging the Case Management Knowledge Framework to illuminate our role in a changing landscape. Featuring Sara Franko of Capitol Counsel LLC and Patrice Sminkey, the Commission’s chief executive officer.
  • Current, Evolving and Always Available: The Case Management Body of Knowledge (Volume 2, Issue 1)
    The interest and opportunity in case management is rapidly expanding, among those who practice and also among the professionals who deliver and those who regulate health care. The science, practice and policy of case management are changing, increasing the need for to up-to-date, easily accessible information about case management knowledge and process. Enter the Commission for Case Manager Certification's Case Management Body of Knowledge® (CMBOK ® ) to address this need and to realize our mission of advancing the practice of case management. Featuring the expert voices of CMBOK Knowledge Editor Hussein Tahan, DNSc, RN and Annette C. Watson, RN-BC, CCM, MBA, the Commission’s immediate past-chair and senior vice president, Community Transformation for Taconic IPA.
  • Care Coordination: Case managers "Connect the Dots" in New Delivery Models (Volume 1, Issue 2)
    One key finding of the Commission’s 2009 Role & Functions survey is that, as complexity of care increases and the demand for accountability grows within new models of care, the role of the case manager is increasing in importance--especially in guiding patient transitions across multiple practitioners and care settings. Featuring experts Janet Tomcavage, RN, MSN of Geisinger Health Plan and Michael B. Garrett, MS, CCM, of Qualis Health.
  • Growing Trend: Case Management Certification Desired and Paid for by More Employers (Volume 1, Issue 1)
    The employer perception of the growing importance of certification suggests that employers view   certification as a quality indicator, a proxy for demonstrating competence that an employer is willing to pay for and even require. Follow the implications of this trend in this issue brief based on findings from the Commission’s 2009 Role & Functions Study and featuring experts Lisa Woodring, LSCSW, LCSW, CCM, RN, director of clinical operations for Clinical Trials Technology, Inc. and Sandy Wederquist, RN, CPUM, CMAC, director of care management for Blue Cross and Blue Shield of Kansas City.