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Most organizations recognize the benefit of hiring case managers with a strong clinical background. Others not only recognize the value of clinical experience — they insist on it.
"The requirement for clinical experience is absolutely essential in a case manager who is managing cases involving catastrophically ill and/or injured individuals," stresses Carrie Engen Marion, RN, BSN, CCM, president of Advocare/Triage in Naperville, IL. "I have personally seen many examples of case managers who did not have the clinical experience they should have had to be managing the cases assigned to them. I have personally been called in to clean up situations where the case managers have clearly been outside the realm of their expertise which resulted in less than desirable outcomes, and, in some cases, unsafe situations."
It seems Marion is not alone in insisting that case managers have an adequate clinical background. More than 78% of respondents to the American Health Consultants/Case Management Society of America (CMSA) 2000 Case Management Caseload Survey reported having more than 10 years of clinical experience compared to 0.6% who reported having less than one year of clinical experience.
Other findings included:
"Case managers are called upon to take on many roles with each case," Marion says. "Many times the case manager has to be the coordinator of all services and health care professionals — the case manager acts as educator, negotiator, support system, and financial consultant."
Marion says the nursing shortage may make it more difficult for case management organizations to find professionals with extensive clinical experience. "The problem is that case management companies/departments may not be able to compete with the hospitals in the realm of salary and benefits, so may not be competitive in attracting professionals who are motivated by those factors," notes Marion. "There will always be companies in case management and managed care that think they can use non-health care professionals for these roles — it’s happening today. It is not a way to do what I would call traditional and holistic case management."
"Clinical experience assures practical knowledge of real care implementation issues," stresses Jeanne Boling, MSN, CRRN, CDMS, CCM, executive director of CMSA. "Each case manager should practice within the scope of their expertise. A healthy part of that expertise," she explains, "is a complete knowledge of the clinical and care implementation issues surrounding their clients. Although the knowledge base varies from practice setting to practice setting, the importance of clinical experience remains critical."
Linda DeBold, RN, MSN, ARNP, ABQAURP, regional manager of case management for Broward General Medical Center in Fort Lauderdale, says that in the acute care setting, clinical experience relates directly to "the success of accurate management of the case and the ability to follow a patient throughout the continuum.
"Without at least five years of experience," DeBold observes, "I have found that case managers lack the ability to gain the respect of the physicians and the nursing staff in the acute setting. Many times the case manager becomes the clinical resource nurse to the staff," she continues, adding that Broward General requires new case managers to have three to five years of clinical experience.
Of course, it’s not easy to discuss the need for clinical experience without first agreeing on the meaning of that two-word phrase. "For nurses, clinical experience is best defined as full-time floor nursing in the acute care setting. I’ve observed excellent results when this full-time experience is in the critical care setting," notes DeBold. "Critical care nurses make excellent case managers because of their critical thinking skills and their ability to negotiate with physicians — two traits essential for good case management."
For the owner of an independent case management company, the essential "experience" she seeks in new case managers includes basic training from an individual’s health care discipline, actual clinical practice, life experiences, and willingness to listen to others with greater expertise. "Experience also comes from taking the time to talk and listen to patients," adds Anne Llewellyn, RN-C, BPSHA, CCM, CRRN, CEAC, owner and independent case manager with Professional Resources in Management Education in Miramar, FL.
As a manager hiring new case managers, DeBold says she looks for professionals with clinical experience which includes both critical care and telemetry. "Our hospital has only two units with no monitoring going on. I need case managers who understand the technology used."
Marion also requires a minimum of three to five years of clinical experience in new case managers, noting that this is a policy that is "fairly standard to most reputable companies. I know companies who hire new graduates to do case management. It’s not in the interest of the catastrophic and very complex patients we serve to have someone with no clinical experience and/or judgment managing their cases," she says. "We also require [that] case managers have a level of critical thinking skills, including good written and verbal communication, decision making ability, and the ability to think outside the box — be creative."
But the bottom line is that without clinical experience, applicants need not apply, stresses Marion. "I can’t give them that. Case managers have to know how to get the answers they are looking for and when to ask questions. Many new grads without that clinical experience don’t know those things."
Peter Moran, RN, BSN, MS, Cm, CCM, nurse case manager for Harvard Pilgrim Health Care in Wellesley, MA, and chapter president’s representative for the CMSA, says that inexperience may lead some new case managers looking for black and white answers in a sea of gray. "My concern about hiring inexperienced case managers," he explains, "is that many new professionals are looking for the right or wrong way to do things. Many will look at clinical guidelines and embrace them to the extent that suggested guidelines become their Bible’ and enforced as if written in stone.
"Unfortunately," Moran continues, "much of what we do as case managers falls into what I call the gray zone, where there is no right or wrong answer and the guidelines don’t make sense. Seasoned case managers are more apt to challenge the accepted guidelines and advocate for their clients. New case mangers are often fearful of rocking the status quo.
"I worry about organizations who may want to hire case managers who are green," he notes, "so they can train them the way they want to do case management. They may attract people who fear upsetting the system, and this isn’t always in the best interest of our clients."