Accreditation spotlight moves from case managers to CM programs

Here’s what’s happening and how it may affect you

The era of case management accountability dawned at the beginning of this decade with increased demand for case managers who were bachelor’s-prepared and had proven their professional standards by obtaining appropriate case management certification. The 1990s saw the development of several nationally recognized certification programs for individual case managers and the Case Management Society of America’s Standards of Practice. Now it looks as if two new accreditations designed not for individual case managers but for case management programs will be available before the decade ends.

Both the Commission on Accreditation for Rehabilitation Facilities (CARF) in Tucson and the American Accreditation HealthCare Commission/URAC (Commission/URAC) in Washington, DC, are developing accreditation programs for case management programs that will be available in 1999. "Certification helped us establish a benchmark for individual practice," says Jeanne Boling, MSN, CRRN, CDMS, CCM, executive director of CMSA in Little Rock. "But we’ve still faced the problem of certified individuals practicing in a system that doesn’t always understand what they do. The accreditation of case management organizations will help shape the system to help individual case managers reach the full extent of their practice capability."

"There are certainly benefits to having accreditation," says Guy D’Andrea, vice president of policy for the Commission/URAC. "It’s a quality seal of approval. It gives the entire industry credibility and accountability. It made sense for us to develop the case management program at this time."

Yet case management industry sources tell Case Management Advisor they have several main concerns about the proposed CARF standards. Those concerns include the following:

• Standards in the field review apply to internal medical rehabilitation case managers and external medical rehabilitation case managers who may work for or contract with payers and employers.

• Many of the proposed standards would be nearly impossible for smaller external case management companies and independent rehabilitation case managers to meet.

• Case management clients soon may look for and even require that case managers work as part of an accredited case management program in addition to obtaining appropriate individual accreditation.

• Case managers work for many different populations. If specialty program credentials are developed for each different population they served, it would become difficult for case management programs to become accredited, especially if there were significant differences in the accreditation criteria.

• Requirements for accreditation may find their way into legislation.

However, Don Galvin, PhD, president and chief executive officer of CARF, notes that accreditation is a voluntary process. "Case management programs have a right to choose whether or not they wish to be accredited by us. We are simply offering a choice in response to our constituency — medical rehabilitation case managers — who want recognition for what they do."

Both CARF and the Commission/URAC say they are keeping the lines of communication open to avoid situations that would require case management programs to be accredited by both organizations. "We have some appropriate concerns about duplicating each other. Neither of us wants that to happen. We want to reassure the industry that we are in communication," says Galvin.

"We’re satisfied that there’s no significant overlap between the two accreditation programs," agrees D’Andrea. "CARF is primarily targeting facility-based case management programs, and we’re leaning toward payer-based programs."

CMSA also has kept a close watch on both accreditation standards. "Of course, we want to see the two accreditation programs as streamlined as possible," notes Boling. "We are working with both groups in their efforts to make these two programs complementary with no onerous duplication of efforts placed on case management programs."

As for the potential for accreditation to be mandated by legislation, D’Andrea says accreditation actually may benefit case managers. "The decision to pursue health care legislation occurs independently of accreditation," he notes. "Accreditation provides a common basis for legislation. The states will do a better job regulating case management if they base legislation on a common set of standards."

What’s ahead

The CARF standards have been approved by the organization’s board of trustees and will be available to the public in January. Those who have seen drafts of them say they are more than 50 pages long and very detailed.

Christine MacDonnell, national director of CARF’s medical rehabilitation and adult day services divisions, says the standards were developed by an international advisory committee of health care professionals in the United States, Canada, and Europe.

The standards address the following:

Leadership. This section addresses who is responsible for managing and directing medical rehabilitation case management. This section also outlines which leadership would be responsible for various areas of case management activity, such as fiscal management, ethics, strategy, health, safety, and transportation.

Information and outcomes management. This section addresses how information is gathered at both the level of the individual and the program to determine the outcomes of work completed by case managers. It also discusses public disclosure of information gathered.

Rehabilitation process for persons served. This section addresses the rights of the client and how case managers interact with the client and the rehabilitation team.

Beta testing will begin next spring

Other key concepts addressed in the CARF standards include:

• Full participation of the case manager in decision making related to the services, equipment, and supplies provided to the persons served, community resources used, and efficient movement of the client through the continuum of care.

• The role of the case manager in the continuum of care and use of the continuum of care.

• Coordination with all stakeholders.

• Advocacy for clients.

The CARF case management standards will be published in the organization’s accreditation manual in January. Field-testing will begin in July.

The Commission/URAC standards will be available for public comment later this month. "We are also posting the standards on our Web site so we can get broad input," D’Andrea says. "After public comment, which will be a two-month process, we will beta-test the standards in real-world settings beginning in March or April 1999. Organizations interested in serving as beta testing sites are still welcome to contact us."

The standards focus on six broad categories, says Kathleen Ward Douglas, RN, MPA, CCM, assistant vice president for disease management of Health International, a Scottsdale, AZ-based medical management company, and chair of Commis sion/URAC’s case management advisory committee. Those categories are:

• case management program characteristics and scope;

• staff qualifications;

• accessibility requirements;

• documentation and information systems;

• patient protection;

• quality management structure and staffing.

"The purpose of these standards is to set realistic goals for managed care organizations regarding these concepts," she says. "The committee is large and diverse. We have committee members from a variety of professional disciplines and practice settings. The committee has worked hard to keep the standards and principles flexible yet meaningful. These new standards will provide additional accountability for case management. The process will acknowledge that case management is a major health care strategy.

"I really believe that this process will advance the evolution of case management as a health care concept into the year 2000," Ward Douglas says. "It will solidify the significance of the practice of case management. Accreditation will be a mark of distinction for purchasers — a guarantee for consumers that there is a level of excellence."

[Editor’s note: To review the public comment draft of the Commission/URAC standards, visit the Web at or call (202) 216-9010. CARF can be contacted at (520) 325-1044 or on the Web at]