Who is qualified to do case management?

Arguments continue in the debate

It’s the question that has plagued case management for years: Who is qualified to be a case manager? Case managers come from more than one health care discipline and have an alphabet soup of credentials available to them, but Case Management Advisor asked experienced case managers to tell us which qualifications really count.

"I am sure that many people will disagree with me and may even be angered by my opinion. However, I think case management is a profession that should only be attempted by those with a medical/nursing background," says Deborah Dunn, RN, BS, CCM, regional supervisor for Kemper Insurance, a workers’ compensation company in Plantation, FL.

"Only registered nurses or physicians are qualified to be medical case managers. We handle long-term disability and workers’ compensation cases. I have made a rather informal study of the difference in case management between nurses and nonmedical case managers. I have found that nonmedical personnel do not have the background or knowledge necessary to understand pertinent issues as they relate to specific diagnosis or treatment plans."

"Nurses are trained in assessment and often find contributing factors to disease states or injuries that the patient may have intentionally or unintentionally deleted from his health history," Dunn says. "This may be uncovered by something the patient says, or fails to say, or by the nurse noting a physical abnormality in the patient. Often these cues are subtle, and identification requires a solid clinical background."

Others agree with Dunn, but with certain exceptions. "As a registered nurse, I also believe that most case managers need to have specialized knowledge regarding pathophysiology and the impact of concurrent disease," says Cynthia E. Whitaker, RN, BSN, CCM, president of RNS Healthcare Consultants in Sacramento, CA, and of the Case Management Society of America in Little Rock, AR. "The truth is that the basic nursing curriculum does not prepare nurses to case manage clients such as the frail elderly, the developmentally disabled, and those with problems of substance abuse. Unless nurses have received additional post-graduate education and working experience in these types of clients, I believe they are best served by the case management expertise of social workers, counselors, and others."

"I agree that who is qualified to do case management depends on the setting and type of case," says Jean Beaubien, RN, BSN, CRRN, CDMS, CCM, rehab manager for Rehab Plans, a workers’ compensation and auto no-fault case management company in Southfield, MI. "We have a vocational consultant who works as a case manager after initial medical needs have been addressed. Nurses are not trained to address occupational, vocational, and speech issues. We have a variety of professionals that work together, and I believe that we learn and gain from each other. Anyone who thinks that only an RN can do case management in all situations is taking a view that is too narrow."

Beaubien notes that the individual is as important as the degree and credentials when determining who makes a qualified case manager. "I train case managers, and even professionals who have reached the top of their professions have to start with a whole new learning curve when they come into case management," she says. "It takes three months before new case managers feel comfortable with the paper flow. At six months, they suddenly realize all the things they still need to learn. At one year, they are more confident."

The Foundation for Rehabilitation Educa- tion and Research in Rolling Meadows, IL, the Association of Professional Geriatric Care Managers in Tucson, AZ, and other interested care and case management organizations met in October 1997 to develop a better understanding and definition of care management and case management and put to rest some of the issues in this long-standing debate. (For more on the meeting, see Case Management Advisor, December 1997, pp. 201-204.)

"The same debate about nurse case managers vs. non-nurse case managers was heard when the Commission for Case Manager Certification [CCMC] in Rolling Meadows, IL, first developed the certified case manager certification. The argument was made that CCMC absolutely had to let non-nurses take the exam because other disciplines besides nursing were doing case management and doing it well," Beaubien says. "We have to go into the year 2000 with the attitude that everyone has a part in this case management profession. We have to keep the client actively engaged in assisting with the process and never forget to advocate for the patient at all times."