Professional Development, Certification, and Accreditation in Case Management
Marietta P. Stanton
Hussein M. Tahan
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
Identify those organizations and standards that exert an influence over case management education, training, certification, and accreditation.
Describe key components of the case manager’s initial education and clinical preparation.
Describe competency-based approaches to case management education and training.
Examine the relationship between various certifying agencies in case management and case management education and training curriculum development.
Delineate topics appropriate for training and continuing education or staff development in case management.
Determine the differences in academic preparation and how these relate to basic and advanced levels of case management practice.
Define credentialing, certification, and accreditation.
List the components of the credentialing process employed for accreditation of case management organizations, programs, or services.
IMPORTANT TERMS AND CONCEPTS
Academic Preparation
Accreditation
Accreditation Standards
Case Management
Case Management Philosophy
Center for Case Management
Certificate
Certification
Core Components of Case Management
Credentialing
Licensure
Professional Development (Standards of Care and Practice)
Introduction
A. Essential information related to the education, clinical preparation, and work-life experience of case managers comes from several important sources.
Professional organizations, case management certification organizations, regulatory bodies, and accreditation agencies provide an overview of the knowledge areas required for case management education and training.
Certification in and accreditation of case management are valued and therefore are powerful forces in shaping training and educational requirements for case management preparation.
B. Educational preparation of case managers is critical to the success of the case manager’s role in the health care system. Consensus information about core areas of knowledge needed by case managers for basic, intermediate, and advanced levels of practice and competence have been delineated in the literature.
C. Because case management preparation is dependent on both the experience and educational preparation, using competency standards for case management in the clinical area is an effective mechanism for training, continuing education, and ongoing professional development.
D. Academic preparation and clinical experience are determinants of knowledge, competence, and skill levels of the case manager. There are case management skills that appear to be at the basic or entry level of practice, while there are others that appear to be at the advanced level of practice, for example, master’s-degree level of academic preparation.
E. Necessary training and education in specialty areas may vary according to the specialty itself and related certifications.
F. Certifications in case management have been in existence since the early 1990s. Currently, there are more than 30 different certifications in case management or its related practices. Despite the popularity, this presents a challenge for the interested case manager in deciding which one best fits her or his specialty practice or professional discipline.
G. Certification, accreditation, and credentialing are three terms that tend to be confused and often used interchangeably. These terms are different and professionals in the case management field should be clear about their meaning and intent and should use these terms appropriately (see key definitions section).
Descriptions of Key Terms
A. Accreditation—A process in which a nationally recognized agency (other than a health care provider organization), usually nongovernmental, assesses a health care organization’s operations and performance to determine whether it meets a set of nationally recognized and accepted standards, mainly designed to demonstrate quality and safe care.
B. Case manager—A health care professional who is responsible for coordinating the care delivered to a group of patients based on diagnosis or need. Other responsibilities may include patient and family education, advocacy, management of delays in care, utilization management, transitional planning, and outcomes monitoring and management. Case managers work with people to get the health care services and other community resources they need, when they need them, and for the best value (quality, safety, and cost).
C. Certificate—A document awarded to affirm that an individual participated or attended a given educational program. It can be provided by any professional agency (private or public, for-profit and not-forprofit), university, or college. Usually, a certificate is not nationally recognized in any form other than an educational credit.
D. Certification (individual)—An official form of credential that is provided by a nationally recognized governmental or nongovernmental certifying agency (i.e., credentialing body) to a professional who meets a set of predetermined eligibility criteria and requirements of a particular field, practice, or specialty. It usually signifies the achievement of a passing score on an examination prepared by the certifying agency for that purpose. It also denotes an advanced degree of competence.
E. Certification (organization or program)—An official form of accreditation that is provided by a nationally recognized governmental or nongovernmental agency to an organization or a program within an organization (e.g., center of excellence) that meets nationally recognized requirements or standards of quality and safe performance.
F. Consensus—Agreement in opinion of experts. Building consensus is a method used when developing case management plans.
G. Credentialing (individual)—The process used to protect the consumer and to ensure that individuals hired to practice case management are providing quality case management services. This involves a review of the provider’s licensure, certification, insurance, evidence of malpractice insurance (if applicable), performance, knowledge, skills and competencies, and history of lawsuits/malpractices.
H. Credentialing (organization or program/service)—The process used in the review of a case management program or organization to ensure that it meets nationally recognized industry standards of quality. This is necessary for the provision of quality case management services and to protect the consumer.
I. Credentials—Evidence of competence, current and relevant licensure, certification, education, and experience.
J. Licensure—A mandatory and official form of validation provided by a state governmental agency affirming that an individual has acquired the basic knowledge and skill, and minimum degree of competence required for safe practice in one’s profession such as nursing, medicine, and social
work. This is usually conducted in compliance with a statute for a given occupation and carries the expectation that the licensed individual act in an unsupervised way.
work. This is usually conducted in compliance with a statute for a given occupation and carries the expectation that the licensed individual act in an unsupervised way.
K. Standard (individual)—An authoritative statement by which a profession defines the responsibilities for which its practitioners are accountable.
L. Standard (organization)—An authoritative statement that defines the performance expectations, structures, or processes that must be substantially in place in an organization to enhance the quality of care.
M. Standards of care—Statements that delineate care that is expected to be provided to all clients. They include predefined outcomes of care that clients can expect from providers and that are accepted within the community of professionals, based on the best scientific knowledge, current outcomes data, and clinical expertise.
N. Standards of practice—Statements of acceptable level of performance or expectation for professional intervention or behavior associated with one’s professional practice. They are generally formulated by practitioner organizations based on clinical expertise and the most current research findings.
Applicability to CMSA’s Standards of Practice
A. The Case Management Society of America (CMSA) explains that case management practice extends across all health care settings and professional disciplines (CMSA., 2010). This results in availability of case managers in virtually every practice setting along the continuum of health and human services. It also indicates that case managers come from diverse health care and professional backgrounds.
B. In its standards of practice for case management, CMSA describes the requirements for the case manager role including education, licensure, or certification and other qualifications.
C. The standards emphasize that case managers should maintain knowledge, skills, and competence in their area of practice. It states that they possess:
Current, active, and unrestricted professional licensure or certification in a health or human services discipline that allows the case managers to conduct an assessment independently as permitted within the scope of practice of the discipline they belong to (e.g., nursing, social work).
Baccalaureate or graduate degree in social work, nursing, or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of the persons being served (CMSA, 2010).
The educational degree must be from an institution that is fully accredited by a nationally recognized educational accreditation organization, and the case manager must have completed a supervised field experience in case management, health, or behavioral health as part of the degree requirements (CMSA, 2010).
D. Case managers according to CMSA must demonstrate professional standing and maintain their qualifications at all times. They are expected to meet the requirements described in Box 17-1.
E. This chapter focuses on the training and education of case managers and how to seek certification or accreditation. These topics support the CMSA
standards of case management practice and assist case managers and organizations in the implementation or use of the standards.
standards of case management practice and assist case managers and organizations in the implementation or use of the standards.
BOX 17-1 CMSA’s Requirements for the Case Manager Role
Possession of the education, experience, and expertise necessary for the case manager’s area(s) of practice
Adherence to national and/or local laws and regulations that apply to the jurisdictions(s) and discipline(s) in which the case manager practices
Maintenance of competence through relevant and ongoing continuing education, study, and consultation
Practicing within the case manager’s area(s) of expertise, making timely and appropriate referrals to, and seeking consultation with, others when needed
Pursuing professional excellence and maintaining competence in practice
Promotion of quality outcomes, including safety, and measurement of those outcomes
Supporting and maintaining compliance with federal, state, local, organizational, and certification rules and regulations
From Case Management Society of America (CMSA). (2010). Standards of practice (2nd ed.). Little Rock, AR: Author.
F. The CMSA standards of practice for case management are an excellent source for the development of professional development, training, and educational programs. They also are beneficial in guiding the development and implementation of formal academic programs. In this regard, the standards clearly identify a list of topics that can be addressed in the training and educational programs.
Education and Training of Case Managers
A. Education and training programs for case managers are developed based on the standards of practice, evidence-based outcomes, accreditation and credentialing criteria, and certification examination content.
B. URAC in its case management accreditation standards describes the key elements of case management education and training programs. These standards state that case managers must be educated in the specific areas that are relevant to the case management practice in the individual organization or work setting (Box 17-2). URAC also explains that training does not need to be completed on an annual basis; however, it encourages ongoing professional development (URAC, 2013).
C. Education should include knowledge of the organization’s policies and procedures, case management process, state requirements, professional roles, organizational ethics and confidentiality, health care requirements of specific populations, URAC standards, CMSA’s standards of practice, knowledge domains of the CCMC certification in case management, and certification examination blueprints of other certifying agencies.
D. URAC encourages case managers to engage in annual training and recognizes major case management certifications.1
E. The Commission for Case Management Certification (CCMC, 2015) has identified eight essential activities of case management that may be included in training and education programs:
BOX 17-2 Topics of Case Management Training Programs According to URAC
The health care organization’s case management-specific policies, procedures, evidence-based plans of care, and quality management program
The laws and regulations that apply to the case management program and based on the appropriate jurisdiction (i.e., local, state, and federal)
Case management roles, responsibilities, and accountabilities
Scope and standards of case management practice reflective of national and widely accepted or recognized knowledge domains
Cultural competence, health literacy, and motivational interviewing and principles for client engagement
Any special requirements based on the particular clients the organization and the case management program serve
Available resources to support case managers in their roles
Professional conduct and ethical practice
Coordination and transitions of care
Case management evaluation and measurement of outcomes
Assessment
Planning
Implementation
Coordination
Monitoring
Evaluation
Outcomes
General (across all activities)
F. The CCMC has also delineated five core components of case management knowledge necessary for effective performance.2 These core components provide a basic foundation for case management education, training and continuing education, and competencies (Tahan, Watson, & Sminkey, 2016):
Care delivery and reimbursement methods
Psychosocial concepts and support systems
Rehabilitation concepts and strategies
Quality and outcomes evaluation and measurements
Ethical, legal, and practice standards
G. The CCMC also specifies criteria for validating practice for certification as a certified case manager (CCM). For example, an individual can practice under the auspices of a CCM for 12 months or 24 months under the supervision of a case manager. There is a mechanism for validating experience as a self-employed case manager.
H. The Center for Case Management (CFCM) delineates specific content for the Case Management Administrators Certification (CMAC).3 Topics covered in the exam include (CFCM, 2015) those described in Box 17-3.
I. The CMAC demonstrates professional recognition of the knowledge required to be a case/care management administrator, director, manager,
educator, or supervisor of any case management service or independent practice throughout the continuum of health care. This certification is also offered to case management faculty in the academic setting (CFCM, 2015).
educator, or supervisor of any case management service or independent practice throughout the continuum of health care. This certification is also offered to case management faculty in the academic setting (CFCM, 2015).
BOX 17-3 Domains of the CMAC Certification Examinations
Identification of at-risk populations
Assessment of clinical systems’ components
Development of strategies to manage at-risk populations
Leadership for change
Market assessment and strategic planning
Human resource management
Program evaluation through outcomes management
J. Case management administrators and faculty lead organizations in the development and implementation of strategies to achieve clinical quality, financial, and satisfaction outcomes. Their activities may include education, program design and collaboration, direct supervision, consultation, and evaluation.
K. CMSA provides a foundation for education of case managers with the specification of their standards of practice (2010). The standards for care and the related “performance evidence specifications” are essential elements in case management education and training.
Educational components include client identification and selection for case management services, assessment and problem or opportunity identification, development of the case management plan, implementation and coordination, evaluation of the case management plan, and termination of the case management process (CMSA, 2010).
Each step in the case management process provides measurement guidelines that give direction for education and training.
Performance evidence prescribed by CMSA in the area of quality of care, qualifications of case managers, collaboration with patients and providers, as well as legal, ethical, and advocacy considerations for case management practice also provide direction for education and training.
CMSA’s standards of practice address resource management and stewardship, as well as provide measurement guidelines for each of the performance evidence, resulting in a comprehensive overview of the requirements for the training, education, and ongoing continuing development of case managers.
The CMSA standards specify the educational preparation and certification qualifications for case managers, including professional licensure, specific training related to case management and a minimum number of years of experience related to the health needs of the target population, appropriate continuing education, and maintaining certifications. These specifications regarding preparation have laid the groundwork for consideration of case management as advanced practice in nursing (CMSA, 2010).
L. The American Nurses Association (ANA), through its credentialing arm (the American Nurses Credentialing Center [ANCC]), has identified five components of case management practice reflected in the certification examination. These are
Fundamentals of practice
Resource management
Quality management
Legal and ethical practice
Education and health promotion (ANCC, 2013)
M. The education and training for case management has included extensive experience as a licensed professional and past practice as a case manager. The practice element in case management should be coupled with education and training.
N. Areas of specialization, like workers’ compensation, disability case management, or maternal child case management, also provide additional foundational areas for case management education and training. Many of these are similar to the CCM in terms of content and focus.
Consensus Areas for Case Management Education: Core Components
A. The literature in case management provides an indication of what needs to be included in case management education and training programs.
B. Reviewing previous research studies and other published materials on case management education and training provides insight into topics that should be included in both formal and informal educational programs. This also promotes the development of evidence-based training and education curricula.
C. Research in this area is lacking; however, findings from past old surveys are still relevant today. Examples are the following:
A large survey of case managers conducted by Leahy et al. (1997) provides an in-depth description of case management services in a variety of work settings. Foundational elements were abstracted and five core areas were identified:
Coordination and service delivery
Physical and psychosocial issues
Benefit systems/cost-benefit analysis
Case management concepts
Community re-entry
In another survey of nurse educators, content areas for case management were grouped into four levels of complexity as well as by content (Kulbok & Utz, 1999). These were
Background in history and trends
Case management process (basic levels)
Ethical and legal issues (intermediate level)
Case management research (advanced)
D. Benner and colleagues (Kulbok & Utz, 1999) categorized the stages of skill development as novice, advanced beginner, competent, proficient, and expert.
Applying these levels to case managers, a new graduate would be an advanced beginner.
Through experience, maturity, and formal and informal learning, the case manager would progress through the experience levels to expert level within the role of the case manager.
For some expert-level case managers with advanced education, a natural progression into a leadership position as a case management director responsible for educating and mentoring other beginning or intermediate case managers may occur.
Based on this notion, much of the content that is appropriate for nursing administrators is also appropriate for case management administrators.
E. In social work, graduate courses in case management assist social workers in preparing for advanced practice. Core elements that have been integral to graduate coursework for social workers include five content areas that give case management a transdisciplinary character (Moxley, 1996). These content areas are:
Policy environment and problem formulation
Diverse purposes, aims, and models of case management
Context of case management practice
Role definitions and staffing implications
Ethical challenges to practice
F. Not all case management is advanced practice, nor does it require graduate education. However, it is becoming abundantly clear that in the past several years, case managers are performing more complex duties that appear to match the competencies and skill levels of other advanced practice roles.
G. Case managers perform their roles at individual, group, and system levels. Case management at the system level requires advanced practice skills that are traditionally not found in entry-level professional education (Stanton, Swanson, Sherwood, & Packa, 2005).
H. The differences between basic and advanced case management skills are depicted in Tables 17-1 and 17-2 (Stanton & Dunkin, 2002).
TABLE 17-1 Case Management at the Basic Practice Level: An Overview of the Role of the Nurse Case Manager | ||||||||||
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TABLE 17-2 Case Management at the Advanced Practice Level: An Overview of the Role of the Case Manager | ||||||||||
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Basically, case management at the baccalaureate level focuses on the basic concepts and principles of case management practice including care coordination and transitions of care and how these topics apply to caring for individual clients.
Case management at the graduate level focuses not only on the knowledge areas covered in baccalaureate programs but also on use of evidence-based practice guidelines or plans of care, quality management, ethical and legal practice, chronic care management, and research. It also assists the case manager student in understanding the application of these knowledge areas in the care of cohorts of clients or a larger population with the intent to improve the health of a community.
Outcomes at the basic level focus on clinical, satisfaction, or care experience, cost, safety, and functional outcomes for the individual client.
Outcomes at the systems level focus on a roll-up and analysis of these individual outcomes for the entire group of patients, a population, or a community.
Approaches to Case Management Education and Training
A. Professional licensure is the basic mechanism for credentialing of case managers. Certification in case management has become increasingly available and is thought to demonstrate advanced knowledge, experience, and competence.
B. There is a growing list of distinct certification examinations in case management practice. Some of the better known and well regarded have been influential in determining content for case manager education and training programs and curricula. They also provide entry level for case management clinical knowledge and skills acquisition.
C. Competency in case management is paramount. Individual competence is the foundation or backbone for the case management process and for effecting desirable outcomes (i.e., quality, safety, care experience, and cost-effectiveness).
A variety of methods can be used to assess, develop, and evaluate competency, including self-assessment tools, orientation curricula, competency and skills checklists, and/or on-site/online education (Stanton, Swanson, & Baker, 2005).
Assessing competence can be used to determine beginning competence or increasing knowledge and skills, and as a mechanism for ongoing performance appraisal.
D. There are continuing education and certificate programs available as preparation courses in case management practice. The better educational programs have core accreditation from URAC and/or continuing education approval by the CCMC or other professional organizations.
E. There is a large number of graduate-level programs in nursing and social work that include case management content, especially in the preparation of clinical nurse specialists, nurse practitioners, and master’s degree-prepared social workers. Some schools also include case management courses in their undergraduate curriculum.
BOX 17-4 Types of Case Management Training and Education Programs
Noncertificate programs offered by health care organizations as part of orientation or inservice education sessions.
Certificate programs offered by independent agencies through conferences conducted for the purpose of continuing education in case management, such as those offered by Contemporary Forum, CMSA, and American Health Consultants.
Multiple-credit certificate courses offered by colleges and universities.
Postbaccalaureate certificate programs also offered by universities and colleges.
Master’s degree-granting programs; that is, graduate-level educational programs offered by universities or colleges.
F. Several graduate programs in nursing focus on case management as a specialty at the graduate level of nursing practice. Although limited, there are also programs that combine nursing and social work with a focus on case management and in the form of interprofessional education.
G. The case management literature describes a variety of training and education programs for preparing case managers for their roles:
Degree- or non-degree-granting programs
Programs offered by health care organizations in the practice sector, independent continuing education agencies, or colleges and universities
H. The case management training and education programs are classified by Cesta and Tahan (2003) into five types or levels (Box 17-4).
I. Case management training programs that are offered by health care organizations may include topics such as those described in Box 17-5.
J. Case management educational programs offered by colleges and universities are considered formal programs and may include courses that cover topics such as those listed in Box 17-6.
BOX 17-5 Topics Addressed in Informal Case Management Training Programs
Leadership
The change process
Communication and interpersonal skills
Case management concepts, principles, and models
The case management process
The role of the case manager
Care coordination and interdisciplinary rounding
Utilization review and management
Transitional and discharge planning
Case management plans and tools
Legal and ethical considerations
Patient and family/caregiver engagement, education, and patients’ rights
Motivational interviewing
Risk stratification
Quality management and safety
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