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Every case manager has a vested interest in the training of newly hired case managers. Simply put, when new case managers are inadequately prepared for their new roles, it reflects poorly on all case managers and their organizations, say case management trainers.
"Many organizations erroneously believe that a health care professional has the knowledge and skills needed for case management practice from the education and clinical practice," says Sandra L. Lowery, RN, BSN, CRRN, CCM, president of CCMI Associates, a case management consulting and training firm in Francestown, NH, and current national president of the Case Management Society of America (CMSA) in Little Rock, AR. "These organizations often do not understand the specific areas of knowledge and skill that are unique to case management practice. Or, they assume when they hire an experienced case manager or a certified case manager the individual requires no additional training."
While there may be some validity to that assumption, argues Lowery, in many instances the case management experience gained while working for one employer may not be transferable to other practice settings. "For example, if a case manager had experience in a health care plan where the case manager’s role was primarily benefit management, the case manager will not have the appropriate experience for a case management role in a hospital or workers’ compensation setting, even though some of their knowledge and skill may apply," she explains.
Lowery says this leaves the new employer with two challenges: Not only does this new hire need to learn the principles of case management practice and how to apply them in a different setting, the new hire must now "unlearn" certain concepts, which is sometimes more difficult than learning new ones. "This is more common than one would think due to the fact that the title case manager’ does not always correspond to the role as defined by the CMSA standards of practice," she adds.
Perhaps that’s why, without fail, good case management training programs begin with a general organization overview.
Newly hired case managers at Boston-based Liberty Mutual spend their first weeks on the job working with their assigned manager in their own branch office becoming familiar with their work setting, configuring their work station and receiving an organization orientation program designed by the human resources department, which provides background on the company.
They also receive passwords and user identification codes for the computer system they will be using, and even begin running through various training applications on the computer system. "All of that preliminary work must be done before they come to the training center in Dover for training in medical case management," says Judith L. Strate, BSN, CCM, regional director of training for medical case management with Liberty Mutual’s commercial professional services-training department in Dover, NH.
New case managers at Owings Mills, MD-based CareFirst BlueCross BlueShield also receive a general organization orientation before working with the case management trainer. "Even after they reach me," says Kimberly Riesenfeld, RN, BSN, CCM, case manager for CareFirst, "I spend time covering general information on the company product lines from traditional insurance through to managed care and government programs. We feel it’s important for our case managers to understand all of our products — even if they will only be working with one product line — before moving on to case management orientation."
Similarly, new case managers at Blue Shield of California’s PPO (preferred provider organization) division in Folsom, CA, spend a day receiving organization orientation from the human resources department and then spend three weeks learning the organization’s computer system, including how to fill in certain fields commonly used by the payer’s case managers, before working with Marlene Underwood, RN, BSN, CCM, and Sandra M. Blacet, RN, BSN, CCM, the continuous quality improvement nurses who provide Blue Shield of California’s case management training program.
ING Employee Benefits, formerly ReliaStar Employee Benefits in Minneapolis, provides new case managers with a training manual that includes information about insurance companies, actuaries, and underwriting, as well as information on the company’s policies. "We also discuss claims procedures and various positions within our department," says Mary Kay Racette, MS, CRC, CDMS, CCM, senior rehabilitation case manager in the disability management services department at ING Employee Benefits.
Case managers also sit down with professionals who perform those jobs within the department. "It’s often more beneficial to observe how the job is performed than to read about it," explains Racette. "Individuals learn in their own way. Generally, I begin by verbally explaining. Then, I give them materials to read. Finally, I give them an opportunity to observe for themselves — it often takes more than one approach before the information is learned."
Some organizations also ask representatives of other departments to come in and speak to new case managers about their roles, or have case managers go and observe other departments to better understand how they interact. "We bring in the managers of different departments to speak to new case managers about their own roles and how those roles support case management," says Strate. "For example, the director of POWER, Liberty Mutual’s rehabilitation at work program comes in to discuss our program, and how case managers can take advantage of it to help employees return to work. The vice president of the PPO network speaks to new case managers about how to find an appropriate network physician."
Having department heads come to speak to new case managers at the Dover training center gives case managers an opportunity to ask questions of senior management they might not otherwise meet, she adds.
After new case managers have been introduced to the organization and the products they will be working with, most training programs move into an orientation to the case management process. And many rely on the CMSA standards of practice as their primary teaching tool.
"After we’ve covered the structure of the business unit the case manager will be working in, and their role within that unit, we move into the definition and actual job duties of a medical case manager," says Strate.
Liberty Mutual clearly delineates between "medical case management" and "managed care," stresses Strate. "We take a look at the history of managed care and utilization management. We go over how to walk that fine line between patient advocacy and appropriate care."
Liberty Mutual describes the role of the medical case manager within its organization, says Strate, in terms of the following five primary functions:
• coordinating medical and rehabilitation services;
• monitoring and evaluating services and outcomes;
• performing medical and disability case management in a timely manner with appropriate follow-up and closure;
• identifying needs, making recommendations, and arranging for durable medical equipment and other necessary services and treatments;
• providing medical expertise to claims case managers.
Liberty Mutual also takes new case managers through the entire case management work process — the continuum of evaluating and putting together plans that produce positive return-to-work outcomes. Strate presents the process formally at the beginning of the five-day training program and then asks case managers to incorporate what they’ve learned into case studies later in the week.
Case management trainers agree that case studies, role playing, and hands-on exercises must play a role in the training process. "There’s simply too much information that must be presented for an individual to absorb it in one week," says Strate. "It’s essential to balance hands-on learning with lecture — we’d lose people if we tried to lecture the entire day."
Underwood and Blacet agree. "We take lots of breaks during the day," says Blacet. "We start each new topic by asking case managers to read through some written material. After case managers read through the materials, we discuss them. And finally, we work through some exercises covering those materials."
Case studies are presented on-line, notes Strate. "We start playing on the computer system and working through exercises from the first day of training. We have test cases built into the training applications which case managers can access. The cases build from the basic to the complicated as the week progresses."
No matter what practice setting they are preparing case managers for, case management trainers cover many of the same areas of case management work processes. Those include:
• Assessment. CareFirst BlueCross BlueShield gives each case manager a copy of the CMSA standards of practice and uses this document as a model for its case management process. "That means that case managers are taught to assess not just medical status, but also psychosocial issues — they’re taught to look at the entire picture," says Riesenfeld.
• Documentation. "I spend a great deal of time on documentation," stresses Riesenfeld. "We work on keeping documentation objective and being careful to avoid subjective assumptions," she says. "I stress repeatedly that their case notes are legal documents which must be complete and accurate. We practice gathering and documenting as much information as possible — especially when they’re doing telephonic case management. Case managers are trained to gather as many facts as possible."
In addition, during their formal training program, case managers are able to access the current cases of other CareFirst case managers to see firsthand how seasoned case managers handle assessment and documentation, notes Riesenfeld.
• Correspondence. Every case management practice works with certain routine correspondence that case managers must become familiar with, say trainers. Blue Shield of California not only familiarizes case managers with those pieces of correspondence, but sets time frames for getting those letters in the mail. "We talk not only about the types of letters they are expected to produce, but also when to get them out," says Underwood.
Of course, no discussion about correspondence is complete without covering patient confidentiality issues in great detail, say trainers. Liberty Mutual and Blue Shield of California both devote a substantial part of their training programs to training case managers how best to protect patient confidentiality.
"We discuss how to obtain consent for release of information from the patient. If the patient is a minor or incapacitated we discuss how to determine whether consent should be obtained from the plan subscriber or another individual with power of attorney for that patient," says Underwood.
Blue Shield of California places strong emphasis on confidentiality and at this point case managers in the PPO division never use the Internet to transfer patient information. "We do have clinical notes accessible by Internet, but only by our nurses," says Underwood. "No one else at Blue Shield has access to those notes."
Faxed information is never sent without a cover sheet that says "for medical use only," adds Blacet.
• Communication. Many training programs, including those developed by Liberty Mutual and Blue Shield of California’s PPO division, use role playing games to help case managers develop the communication skills they need to work effectively with patients and providers. "We stress that they must consider themselves part of the treatment team and approach providers from that perspective," says Blacet, adding that because Blue Shield of California case managers do so much of their work telephonically, "it’s easy for that team focus to get lost."
Role-playing games help new case managers develop a proactive team approach, says Underwood. "Many case managers come from a clinical setting with a nonassertive background. We teach them ways to sell’ their role as case managers and demonstrate how different communication approaches generate different responses from providers."
• Research. Perhaps the most important skill a case manager must develop is how to find answers to questions they don’t know. "We stress that every case manager makes mistakes or comes across questions they don’t know the answer to — it’s part of the learning process," says Underwood.
Trainers can’t anticipate or provide all the information case managers will need, but they can provide them the tools and the skills to research the answers to those questions that arise. To help case managers in this task, Blue Shield of California provides case managers with several resources, including:
— a telephone list of company contacts case managers may encounter or interact with as they work a case;
— updated provider lists with listings of preferred home care agencies, home infusion companies, and other preferred service providers throughout California;
— an intranet system with information on Blue Shield’s products and services.
• Reporting outcomes. Each case management department has different methods for reporting its outcomes and generates different reports.
At Blue Shield, case managers produce cost savings reports. "We take new case managers through the process of identifying and calculating the cost savings generated by their case management interventions," says Blacet. "We have a database case managers are taught to access which includes the average cost of certain services and procedures. For example, if a provider requests that a neonate be placed in the neonatal intensive care unit, and the medical director and case manager determine the child can be sent home safely on a ventilator with home health nursing — there are costs savings gained by sending the child home rather than a prolonged NICU stay."
Liberty Mutual recently developed an on-line pre- and post-assessment to measure the effectiveness of its training program. "The pre- and post-assessments ask the same 48 questions," says Strate, "However, we scramble the order in the post-test."
The 48-question assessment covers both organization-specific information from the human resources department and specific questions about medical case management. "The assessment gives us a sense of each case manager’s strengths and weaknesses," says Strate. "It also gives us instant feedback on how we’re doing as trainers."
In addition to the on-line assessment, case managers are given a graded case study — 80% is a passing grade for these exercises. For case managers who fail to earn a grade of 80% on the on-line assessment and graded case study, Liberty Mutual trainers develop a formal action plan with suggestions for the case manager and the direct supervisor for additional work that should be completed during the subsequent 30 to 60 days. "We work hand-in-hand with the supervisor and the case manager during that period to make sure the objectives on the action plan are met," says Strate, adding that Liberty Mutual’s trainers have rarely had to develop action plans for new hires. "Most case managers earn a passing grade of 80% by the end of their training program. Yet, even for those with passing grades, we talk with the direct supervisor about areas they will want to continue working on with the case manager to improve."
Case managers must be aware of so many issues, from legal concerns to understanding insurance benefits, says Penny Burman, RN, BSN, CCM, supervisor of case management for Blue Cross/Blue Shield of North Dakota in Fargo, that creating a training program that provides case managers with all the knowledge they need would be impossible. "Sometimes, the case manager’s greatest skill is not knowing the answer right away, but rather knowing where or who to get the answer from," says Burman.
Perhaps that’s why case management trainers interviewed by Case Management Advisor stress that an extended mentoring period is an absolute necessity.
"In my 15 years of training case managers," says Lowery, "I find that it takes a minimum of six months for an experienced health care professional to achieve the minimum competencies needed for effective case management practice. Even with specific education in case management principles and workshops, mentoring is a process that is a necessity for the learner to comprehend the application of principles they have learned in a classroom setting."
Blue Shield of California’s PPO division assigns all new case managers a seasoned case manager to act as a preceptor, or mentor, for at least one year. "It takes several years for a professional to become a proficient case manager," says Blacet. "You must gain a variety of experiences with different cases and situations before you learn the necessary skills to quickly prioritize the needs of a particular patient."
New case managers at CareFirst BlueCross BlueShield are given one case to work through with an experienced case manager almost "side by side" before taking on a case alone, says Riesenfeld. "After that, we provide case managers with a checklist which includes all of the pieces that must be covered for every case and their mentor remains available to them as a continuing resource. Mentoring goes on forever — we’re all continuously learning something new."
At ING Employee Benefits, the majority of the training process comes through mentoring. This is possible, says Racette, because ING only hires case managers with master’s-level vocational education. "We receive training in the case management process as part of our vocational training — new case managers come in with a basic understanding of the case management concept."
With that in mind, Racette orients new case managers to ING’s philosophy, systems, and work processes by working side by side with them beginning with basic job functions and becoming more specific as they gain competence. "I may give case managers an assignment to look something up for me on a current claim. I know the answer, but they might not realize that I know it."
Case management trainers agree that new case managers may benefit from observing different case managers, but not too early in their training. "It’s difficult for a new person coming in to be exposed to too many different case management styles at once," notes Racette. "We all have different styles and mine may not be comfortable for them in the long run, but until I’m confident new case managers have a good grasp of how to work through a case, I do all the mentoring myself."
In addition to ongoing mentoring, most trainers audit the work of new case managers for a prolonged period of time. "When case managers first complete their training, we audit 100% of their cases," says Blacet, adding that for most new hires this 100% auditing period lasts about one month. "Once we feel that they are consistently doing a good job evaluating cases, planning, implementing, monitoring, and documenting cases, we drop down to auditing about 50% of their cases."
Once case managers demonstrate adequate competency, Blacet and Underwood drop to auditing their cases quarterly. In addition, case managers at Blue Shield of California’s PPO division are audited by their peers monthly. Case managers must maintain at least a 90% accuracy rate, adds Underwood.