Has New Hampshire board drawn the first of many lines in the sand?

Case managers in New Hampshire denied RN license renewal

Several nurse case managers in New Hampshire were stunned recently when the New Hampshire State Board of Nursing denied their applications for renewal of their registered nurse (RN) licenses. The board says the move is a quality control issue designed to protect consumers in the state of New Hampshire.

Case management leaders warn that this policy, if it spreads, has far-reaching implications for all case managers, such as keeping nurses from acting as case managers.

"It came to our attention about a year ago that there were nurses in case management positions that did not require that the person holding the position be a registered nurse," says Doris Nuttelman, RN, EdD, executive director of the New Hampshire State Board of Nursing in Concord. "We have an active practice requirement. If an employer hires an RN as a case manager because the job requires the special skills and knowledge of a registered nurse, then the nurse case manager meets the practice requirement. If the employer also hires other professionals, such as social workers, to do the same case management position, then we feel that the job does not meet the active practice requirement for registered nurses in this state." She added that the board has challenged, and in some cases denied, license renewal for nurse case managers in payer, acute, and long-term care settings.

If the state board of nursing is simply practicing quality assurance, several industry leaders say, case managers should support the board in its efforts, but not before asking some hard questions. "We have to start some proactive discussions right now about the scope of professional practice as we move forward in new roles," says Brenda-Jean Paradis, RN, regional manager in medical management for Blue Cross and Blue Shield of New Hampshire in Manchester and project manager to accreditation organizations. "To meet standards set by credentialing bodies such as the National Commission for Quality Assurance [in Washington, DC], we only hire RNs to do case management. Yet, we’ve had two RNs here whose license renewal applications are currently under review by the board of nursing."

First, do no harm

"The health care system has required that health care professionals be more flexible and creative in their roles to meet new challenges in the delivery system," notes Sandra L. Lowery, BSN, CRRN, CCM, president of Consultants in Case Management Intervention in Francestown, NH, and president-elect of the Case Management Society of America (CMSA). "I’m concerned that this ruling has broad implications for nurses and other professionals who want to enter specialty areas. It could in essence prohibit nurses from taking case management positions, and my real concern is that consumers will be left without a valuable service."

If a nurse case manager can no longer be relicensed, that nurse is no longer of value to a health care organization, agrees Kathleen Moreo, RN, BSN, BPSHSA, CDMS, ABDA, RN,Cm, owner and president of PRIME, a case management consulting and education firm in Miramar, FL, and president of CMSA. "Organizations will turn to less-appropriately trained and credentialed individuals, and the consumer, the very person the board of nursing is trying to protect, will be harmed."

And it’s not just nurse case managers who are affected when their professional roles are challenged, but all case managers no matter what their discipline. "As case managers, we must work in support of each other regardless of our backgrounds. We spend so much time as professionals developing the skills we need to function as case managers; when one of us is challenged, we must all speak out," says Karen Coish Mackey, BSW, MBA, case manager with Regional Partners in Occupational Health, an occupational health practice in Manchester, NH, and president of the New England Chapter of CMSA. "In the past, I worked as director of an acute rehabilitation case management department which employed both nurses and social workers as case managers. I believe at times the skills of the different disciplines compliment each other. I also believe that there are times, and that there are cases, which require the strengths of either a nurse or a social worker."

CMSA recognizes and supports the right of health care professionals from a variety of disciplines to perform case management. "We [CMSA] believe that case management is an advanced practice based on licensure and certification that can be appropriately done by a variety of health care professionals within the scope of their education, experience, and professional licensure. That’s what it says in the CMSA Standards of Practice." (For more on the standards of practice, see p. 152.)

If you practice outside New Hampshire, don’t be lulled into a sense of false security. The New Hampshire State Board of Nursing has issued a wake-up call, and this is no time to be passive, caution industry leaders.

"I don’t believe for a moment that this issue, and others like it that negatively impact case managers, will end in New Hampshire," says Moreo. "This situation is going to have a ripple effect. This is about health care economics. We are all going to be asked to be more accountable for who we are and what we do. It’s not necessarily a bad thing, but one we must respond to and govern appropriately."

So, what is nursing’?

The American Nurses’ Credentialing Center (ANCC) in Washington, DC, is grappling with similar issues for nurses who hold its nursing case management certification (RN,Cm), which became available in 1997, as well as certifications for other nursing specialties that don’t clearly involve direct patient care. "Many of our recertification requirements have wording that refers to direct patient care.’ Depending on what type of case management you practice, as a nurse case manager you may not even see your patient," notes Mary Smolenski, EdD, RN-CS, director of certification services for the ANCC.

ANCC has had inquiries from nurses concerned they may not be recertified because of the requirement that certified nurses perform "direct patient care," she notes. "We get a great many calls on this issue. Nurses are questioning themselves and the jobs they’ve taken or are considering accepting. They wonder, If I take this job, will it count towards recertification?’ Over the past two years, this has become a huge issue. There are more and more jobs for nurses in the health care industry that don’t involve direct patient care, and case management certainly falls into that category."

ANCC’s 11-member commission is reviewing its definition of "direct patient care," she adds. "One argument that has been discussed is that if a nursing intervention impacts a patient outcome, it could be considered direct patient care even if the nurse did not interface with the patient face to face," she says. "Under that definition, I think nurse case managers could argue that they meet the requirement."

One title, many disciplines

Of course, case management always has been a multidisciplinary field, and nurses are not alone in struggling to define new professional opportunities. The National Association of Social Workers (NASW) in Washington, DC, is the latest group to attempt to establish a quality control process for case managers. Its new specialty certification for social work case managers will be available in late fall. (For a look at certification opportunities for case managers, see Case Management Advisor, January 1997, pp. 1-6.)

"The title case manager’ is used by many different disciplines. Each discipline approaches case management differently. We felt this was an appropriate time to set criteria for social work case managers," says Susan Merrick, ACSW, LCSW, senior staff associate with NASW.

The important thing for case managers to remember is that it’s better to be proactive than wait until it’s time to renew their professional licenses or certifications to review the requirements and take corrective action, if necessary. "This is a wonderful wake-up call for case managers and their employers to review and update their case management job descriptions and consider education and outreach efforts," says Lowery.

Here are five actions industry leaders interviewed by CMA urge case managers to take to protect their professional status:

1. Review licensing and credentialing requirements. Ask your state professional board for a copy of relicensing requirements. If you are unclear about any of the requirements or whether you meet a particular requirement, ask for a clarification before it’s time to renew your license. Take corrective actions, if necessary.

2. Ask for a list of board members. Ask to see a list of the board members, and if you feel that case management is not well-represented, work to make changes in the composition of the board.

3. Write an accurate case management job description. Ask your employer for a copy of your job description. If it fails to accurately reflect your duties and responsibilities, make suggestions for revising it. (See story at right for suggestions on writing case management job descriptions.)

4. Keep your state and national professional associations informed about developments in your area that impact case managers. One person can make a difference. Your professional associations have a strong voice and will use it to help resolve professional conflicts facing case managers. (See p. 153 for examples of how one national association helped its members to resolve a professional conflict.)

5. Educate consumers and policy-makers. If you feel that policy-makers or consumers are misinformed about the role and function of case managers, provide them with educational materials, such as case management standards of practice and codes of ethics.

An opportunity to learn

"This situation in New Hampshire is an opportunity for us as a health management company to educate our members and our state about case management," says Blue Cross and Blue Shield of New Hampshire’s Paradis. "Managed care has been portrayed as the bogey man, and case managers have been along for the ride. It’s time we change that perception and educate people about the patient advocacy case managers provide." (See CMA, September 1999, pp. 137-138, to learn about one managed care company’s big investment in consumer re-education.)

[Editor’s note: For more information or an application for the Washington, DC-based National Association of Social Workers’ new specialty certification for social work case managers, call (800) 638-8799, ext. 447, or visit the association’s Web site at www.socialworkers. org.]