CMSA overhauls case management standards

Standards reflect patient-centered approach

The Case Management Society of America (CMSA) in Little Rock, AR, has revised its Standards of Practice to reflect changes in the health care system and the evolving role of case managers within that system. (See Hospital Case Management, Dec. 2002, p. 192.)

Because those changes have been so profound since the standards originally were developed in 1995, the revision can more accurately be characterized as a major overhaul, says Kathleen Moreo, RN, Cm, BSN, BPSHSA, CCM, CDMS, CEAC, who co-chaired the Standards of Practice Task Force with Gerri Lamb, PhD, RN, FAAN.

According to Moreo, CMSA’s board of directors identified the need for updates in the standards based on emerging trends and changes in the industry such as the growth of managed care and changing demographic trends as well as changes in case manager staffing issues.

Another important issue is the Health Insurance Portability and Accountability Act (HIPAA). The standards, however, are designed to serve as a guideline for the professional practice of case managers rather than a direct response to those new mandates, Moreo says.

"HIPAA is one component of what the case manager has to do in terms of both legal and ethical performance in his or her job," she explains.

There is a section of the standards of practice that addresses consent and patient security in general terms. "It is not applicable strictly to HIPAA but rather appropriate guidelines to be able to practice professionally," she says.

Moreo says the most significant change in focus in the new standards is that they move case management to a more patient-centered approach.

"If you look at the old model under the standards of practice, it had the client and the case manager together in the center and the continuum of care surrounding that," she says. "In the new model, the patient is the center of care."

The new standards also move away from what Moreo calls an insurance focus. "The 1995 standards were very insurance-driven." She says that was because the model of case management at the time was based on payers and independent case managers. "We tried to change the focus and embrace the hospital case manager." CMSA also decided the new standards should be more outcomes driven, with an emphasis on evidence-based practice.

To make sure that the standards reflected the range of disciplines and the expanded settings, CMSA sought representation from as many of the key case management settings as possible, Moreo says. The new standards expand the range of settings to be more representative of where case managers now are practicing. That includes case managers who work in long-term care, those who work directly with consumers, and those who work in the public sector.

Another important area that was added is cultural competence. "We didn’t even address cultural competence in the 1995 standards," Moreo says. The new standards give that area its own section. "We thought cultural competence is reflective of the kinds of caseloads that we are experiencing and the kinds of situations that were coming across in our everyday working environment," she explains.

The new standards also address population-based care instead of only individualized case management. According to Moreo, the 1995 standards focused on costs while the new standards shift the focus to care. "It is care delivery vs. cost efficiency," she says.

The 1995 standards also talked a lot about resource utilization, she adds. Now the emphasis is on resource management and stewardship. "Stewardship is what we hear in the hospital setting, in particular with hospital-based case management," she reports.

"Case managers are not performing resource utilization but rather stewardship." Those standards of practice also recommended specific levels of education and certification. The new standards acknowledge the educational levels of individuals as well as certification but do not make recommendations. "We didn’t feel that was the role of the standards," Moreo says. "The standards are not supposed to police people but rather serve as professional guidelines."

According to Moreo, the CMSA standards are the predominant standards for case management in part because the association was developed as a multidisciplinary professional association.

"CMSA is not married to any one discipline or practice setting," she asserts. "They speak to the importance of certification but are not aligned with any single certification."

She notes, however, that the Commission for Case Manager Certification in Rolling Meadows, IL, has legally adopted the standards. "When you become certified, you have an ethical and legal responsibility to adhere to the CMSA standards of practice," she says.

Moreo adds that it is important for hospital case managers and acute-care coordinators to know where the 1995 standards may have fallen short in identifying guidelines for professional practice by the hospital-based case manager. "I think they will find the 2002 standards to be very embracing of acute-care case management," she predicts.

According to Moreo, the current model of hospital case management was just beginning to emerge in 1995, and there were struggles taking place between social workers and nurses.

"Departments were being put together just to be blown apart and restructured again," she recalls. "There was a lot of volatility in hospital-based case management.

Today, she says that model has "settled in" and is gaining momentum. "That’s why we thought it was important to make sure that we took the emphasis off the payer setting and add an emphasis on acute-care and post-acute care settings," she says.

Moreo says the process put into place to develop the standards was extremely comprehensive. The task force was multidisciplinary in terms of licenses and certifications as well as practice areas. "We also made every effort to get these draft standards out throughout the industry and beyond," she reports.

Making the standards as relevant as possible is critical, she concludes. "The new standards are something case managers can really get their arms around and say: Yes, this pertains to what I do and pertains to the challenges that I might have on any given day.’"