Case managers need extensive education, regular competency exams

Include new employees, longtime staff in the process

B. K. Kizziar calls it case management training by the "Poof!" method. "One day, you're a nurse on the floor. The next day, you're in the case management department and, within a week, Poof! You're a case manager. You have a caseload of your own, and the person who instructed you became a case manager exactly the same way," explains Kizziar, RNC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm.

Few hospitals offer comprehensive orientation and educational programs for new case managers, she asserts. Most of the formal orientation is specific to policy and forms and what tasks they have to do every day.

Typically, after a short period of orientation that involves everything from hospital policies and procedures to regulatory requirements, new case managers have a short period of peer education before they're cut loose to work on their own, points out Lorraine Larrance, BSN, MHSA, CPHQ, CCM, manager with Pershing, Yoakley & Associates, a Charlotte, NC, health care consulting firm.

"Maybe new case managers spend a day or two with another case manager before going out on their own. This tends to perpetuate the idea that case management is task-oriented rather than process-oriented," Kizziar says.

Providing case managers only with internal education and knowledge perpetuates doing things the same way, even if it's not the most efficient or productive way, she adds.

"Developing a training and competency program for the case management department is extremely important, not only for new case managers but for case managers who are already within the organization," Larrance says.

Case managers who are new to the organization and the practice of case management need to learn the basics — what is case management, what are the principles of practice, and what are the case managers' roles in your hospital.

"As a nurse, when I went into case management, I recognized that my clinical nursing skills were directed primarily to the patient's diagnosis and providing quality care, and with that skill set alone, I wasn't prepared for many of the daily case management activities. I didn't have the ability to pull from a set of core principles that direct the care management process, such as understanding and applying payer regulations. I didn't have the ability to look at the physician treatment plan and identify whether or not the patient was ready for discharge or to think in terms of getting the patient ready for the next step," Larrance says.

That's why case management directors should make sure that their case managers are educated about the case manager's role, case management processes, and all of the regulations that affect how they work, she adds.

"I am ultimately held responsible for what my case managers do or what they don't do. If I haven't taken time to educate them and bring them up to speed, it's my error," says Lyn Clark, RN, BSN, case management director at Lake Granbury Medical Center in Granbury, TX.

Because Granbury is a small town in a rural area, there is not a supply of experienced case managers, Clark says. Instead, she created the hospital's first training program for RNs who wanted to become case managers.

The education for new case managers should include topics such as medical necessity, avoidable delays, denials and appeals, and communication with payers and the interdisciplinary treatment team, Larrance says.

"Each of these different case management activities requires specific information related to that area, and they also build upon each other," she says.

Larrance suggests a series of six or seven core education classes from which you can build a competency tool.

Training should combine written work with one-to-one peer communication.

"This gives the individual an opportunity to practice making a determination of patient level of care or come up with a working discharge plan and to have immediate feedback from someone with a skill set that is much stronger than that of a new employee," she says.

It takes at least six months for a new RN case manager to be effective in his or her new role, Larrance says.

It's not enough to educate new case managers; case management training and competencies should be ongoing, in staff meetings, through written communications, and in formal educational sessions, Kizziar adds.

For instance, case management directors could send regular e-mails to the case management staff highlighting what is new or changes in regulations, then follow up in a staff meeting with details.

"Case managers are right in the middle of the continuum of care. They're looking at processes from admission to discharge, and they should be aware of any procedural changes that can affect how they do their job," Larrance says.

The educational process must be ongoing in order for case managers to stay ahead of the curve with regulatory changes coming at them from all different perspectives," she adds.

Understand what drives processes

Larrance recommends that case management directors communicate with their staff weekly about any changes in reimbursement or regulatory requirements that may affect their job.

For instance, case managers may not need to know every detail of coding but they need to be aware of coding changes that potentially affect medical necessity documentation and/or the determination process because often they are the first people to notice that the correct documentation is not on the chart, Larrance says.

"All case managers should understand what drives the processes they use on a day-to-day basis. They should be aware of good stewardship of health care dollars and what impact what they do has on the rest of the interdisciplinary team. It's much easier for people to perform their functions when they understand the basis that is driving the process," she says.

For instance, when medical necessity determines the length of stay for a Medicare patient, case managers should be aware that the orders should clearly state the physician's intent and that documentation in the progress notes should support the diagnosis as well as the treatment plan.

"When a case manager is doing a review with a physician, it's helpful for them to know that the requirements will affect reimbursement and that it's not just something the boss made up," Larrance says.

Case managers in the hospital setting don't always have an opportunity to see each other regularly and exchange ideas on how to manage the care of patients, Kizziar adds.

"When I have consulted with hospitals, I have observed that most of the communication is done by e-mail, but regularly scheduled departmental meetings are essential to discuss regulatory and other changes and how they affect the way the case managers will do their work," she says.

Regularly scheduled department meetings are very important because they give case managers an opportunity to ask questions about changes in regulation, to discuss what they have found effective, and to receive input from other people in the department, Kizziar says.

"I believe that in order to maintain a sound case management department, the staff should attend periodic educational sessions that focus on the core level of case management principles, the core values of what case managers do," Larrance suggests.

If there are new trends or just a particular area within an organization that needs focus, case management directors should bring their staff together and educate them, she adds.

Bring in outside resources to educate your case managers, Kizziar suggests. For instance, invite someone from one of your managed care payers to talk to the case managers about how their company's reimbursement system works, or ask someone from the Centers for Medicare & Medicaid Services to talk about reimbursement.

"Most important is for hospitals to provide support and financial aid for outside education so there isn't a vacuum within the hospital where little information gets in or out. Employees can greatly benefit from outside resources," she says.

Kizziar laments the fact that few employers support continuing education for case managers, eliminating the benefits of attending a conference or class and meeting their peers.

"Professional organizations can provide case managers with excellent overviews of what is going on in the case management world. If the director and/or staff members are active in their local organizations, this can help the case management staff stay current not only with regulations but with what is going on in the community," Larrance says.

Competency programs may differ from hospital to hospital, depending on the case managers' role in the organization.

Look at the role of the case manager within your hospital and set up a monitoring system to evaluate the process, Larrance suggests. Look for gaps to identify areas where you need to educate your staff.

"This not only helps educate the experienced case managers but is extremely helpful when you bring an RN into a case management role," she adds.

Start by creating a job description and base your competency on that, Kizziar suggests.

A case management job description has to be specific to the hospital's objectives and must have measurements attached that are objective, not subjective, she says.

Create a career ladder specific to case management so that it ties in with continuing education, achieving certification, and other education, she says.

For instance, when a new case manager comes into the department, he or she must meet a list of objectives in order to become a Case Manager 1.

When the case manager meets the requirements for the Certified Case Manager exam or other internal requirements, he or she becomes a senior case manager, with a corresponding increase in salary.

Review each case manager's performance at least annually based on the objective measures in the job description Kizziar recommends.

For instance, audit discharge outcomes, resource management, averted costs, and avoidable days.

"The effectiveness of the discharge plan can be measured by following up with patients 72 hours after discharge with a short list of questions.

"This also gives us an opportunity to re-empower the patient and family to be their own advocate and to direct their own care," she says.

Use clerical staff to make the follow-up calls.

Anyone can do the follow-up call because it is a list of objective questions and doesn't involve actually managing the care of the patient, she says.

"If issues are discovered that may endanger the patient or need immediate attention, whoever is making the call can advise a case manager, who can direct the patient or family to the most appropriate resources," she adds.

Preparation for professional competency examinations is another area in which hospitals can help their case managers learn to do their jobs better, Larrance says.

One hospital she worked with held educational sessions for a group of case managers who were preparing for the CCM examination.

The case management director collected information about some of the more obscure areas of the test and provided education for the entire staff.

"It was very much appreciated by those who were preparing for the test and also acted as a stimulant for those who were not taking the examination because studying for the exam didn't seem to be so overwhelming," she says.

(For more information, contact B.K. Kizziar at e-mail:; Lorraine Larrance, BSN, MHSA, CPHQ, CCM at e-mail: