Education, Training, and Certification of Case Managers

Marietta P. Stanton

Hussein A. 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, and certification.
Describe key components of the case manager’s initial education and clinical preparation, including life experience.
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 continuing education and 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.
List essential criteria for certification.

INTRODUCTION

A. Essential information related to the education, clinical preparation, and work life experience of case management practice comes from several important sources.

Professional organizations, case management certification organizations, and accrediting agencies provide an overview of the knowledge required for case management education and training.
Certification in and accreditation of case management are valued and therefore are powerful forces in shaping educational requirements for case management preparation.

B. Educational preparation of case managers is critical to the success of the case management 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 have been delineated in the literature.

C. Because case management preparation is dependent on both experience and educational preparation, using competency standards for case management in the clinical area is an effective mechanism for training, continuing education, and staff development.

D. Academic preparation and clinical experience are determinants of knowledge and skill levels of the case manager. There are case management skills that appear to be at the basic entry level of practice and there are other skills that appear to be at the advanced practice or master’sdegree level of academic preparation.

E. Necessary training and education in specialty areas vary according to the specialty area 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, which 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 used interchangeably. These terms are different and professionals in the case management field should be clear on their definitions and should use these terms appropriately.

KEY DEFINITIONS

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 and other community services they need, when they need them, and for the best value (quality 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-for-profit), 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 to a professional who meets the eligibility criteria and requirement 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.

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.

O. Utilization Review Accreditation Commission (URAC)—A not-for-profit organization that provides reviews and accreditation for utilization review services/programs provided by freestanding agencies. It is also known as the American Accreditation Health Care Commission.

EDUCATION AND TRAINING OF CASE MANAGERS

A. Education and training programs of case managers are developed based on the standards of practice, evidence-based outcomes, accreditation and credentialing criteria, and certification examination content.

B. Key elements for case management education and training are specified in the URAC Case Management Accreditation Standards. These standards specify that case managers must be educated in:

Current case management principles and practices, and
Procedures and knowledge of case management based on nationally recognized standards.

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, and Case Management Society of America (CMSA) standards of practice.

D. URAC requires annual training and recognizes major case management certifications.¹

E. The Commission for Case Management Certification (CCMC, 2005) has identified eight essential activities of case management:

Assessment
Planning
Implementation
Coordination
Monitoring
Evaluation
Outcomes
General (across all activities)

F. CCMC has also delineated six 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:

Case management concepts
Case management principles and strategies
Psychosocial and support systems
Health care management and delivery
Health care reimbursement
Vocational concepts and strategies

G. Similarly, the Center for Case Management (CFCM) delineates specific content for the Case Management Administrators Certification (CMAC).³ Topics covered in the exam include:

Identification of at-risk populations
Assessment of clinical systems’ components
Development strategies to manage at-risk populations
Leadership for change
Market assessment and strategic planning
Human resource management
Program evaluation through outcomes management

H. CMSA provides a foundation for education of case managers with the specification of their standards of practice (2002). The standards for care and the related “performance indicators” are essential elements in case management education and training.

Educational components include client identification and selection for case management services, problem identification, planning, monitoring, evaluating, and outcomes.
Each step in the case management process provides measurement guidelines that give direction for education and training.
Performance indicators 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 also address resource management and stewardship, as well as provide measurement guidelines for each of the performance indicators, resulting in a comprehensive overview of the requirements for the training, education, and ongoing continuing development of case managers.
The standards specify educational preparation and certification qualifications for case managers, including professional licensure, specific training related to case management and a minimum of 2 years’ 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, 2002).

I. The American Nurses Association (ANA), through its credentialing arm (the American Nurses Credentialing Center, ANCC) has identified five components of case management practice—assessment, planning, implementation, evaluation, and interaction (ANCC, 2005).

J. 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.

Persons supervising case managers for 12 months may be able to sit for the certification exam. Similarly, the CMAC exam acknowledges length of experience as a master’s-degree-prepared case manager and case management administrator as a criterion for application to sit for the examination.

K. The education and training for case management has included extensive experience as a licensed professional and extensive practice as a case manager. The practice element in case management should be coupled with education and training.

L. 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.

B. Reviewing previous research studies and articles on case management education and training provides insight into topics that should be included. This also promotes the development of evidence-based training and education programs.

C. A large survey of case managers provided an in-depth description of their services in a variety of work settings (Leahy et al., 1997). Foundational elements were abstracted from this data 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

D. In a survey of nurse educators, content areas for case management were grouped into four levels of complexity as well as by content (Kulbok and Utz, 1999). These were:

Background in history and trends
Case management process (basic levels)
Ethical and legal issues (intermediate level)
Case management research (advanced)

E. Benner and colleagues (Kulbok and 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.

F. 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 five 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

G. 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.

H. 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, and Packa, 2005).

I. The differences between basic and advanced case management skills are depicted in Tables 13-1 and 13-2 (Stanton and Dunkin, 2002).

Basically, case management at the baccalaureate level involves individual case management or care coordination.
Case management at the graduate level focuses not only on individuals, but on cohorts, population aggregates, and disease management groups.
Outcomes at the basic level focus on clinical, satisfaction, cost, 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.

APPROACHES TO CASE MANAGEMENT EDUCATION AND TRAINING

A. Professional licensure is the basic mechanism for credentialing of case managers (Kulbok and Utz, 1999). Certification in case management has become increasingly available.

B. There is a growing list of distinct certification examinations. Some of the better known and well regarded have been influential in determining content for case manager education and training. They also provide entry level for case management clinical skills acquisition.

C. Competency in case management is paramount. Individual competence is the foundation or backbone for the case management process.

A variety of methods can be used to assess, develop, and evaluate competency, including self-assessment tools, orientation curricula, skills checklists, and/or onsite/online education (Stanton, Swanson, and Baker, 2005).
Assessing competence can be used to determine beginning competence or increasing knowledge and skills, and as a mechanism for performance appraisal on an ongoing basis.

D. There are continuing education and certificate programs that are available as preparation courses in case management. The better educational programs have core accreditation from URAC and/or continuing education approval by the CCMC.

E. There are an increasing number of graduate-level programs in nursing and social work that include case management in their preparation of clinical specialists and nurse practitioners. Some schools also include case management courses in their undergraduate curriculum.

TABLE 13-1 Case Management at the Basic Practice Level: An Overview of the Role of the Nurse Case Manager

Aspect	Content
*Practice*	•	Uses basic knowledge of physiology and pathophysiology
	•	Uses basic health assessment skills
	•	Designs, implements, and evaluates health promotion and disease prevention programs for selected individuals
	•	Uses knowledge and understanding of ethical standards of practice according to ANA
	•	Coordinates case management services for individual clients/family
	•	Participates in disease management programs
	•	Fulfills practice standards outlined by AACN, CMSA and CCM
	•	Collects outcomes data
	•	Participates in the development of evidence-based practice guidelines
	•	Collaborates with utilization and resource management in the coordination of patient case management services
	•	Screens patients for case management
	•	Collaborates with discharge planners, social workers, and other internal and external resources to coordinate case management services
*Research*	•	Participates in research studies under the direction of an advanced practice nurse or other professionals
	•	Uses published research to apply to case management practice
	•	Participates on multidisciplinary teams in the provision of case management services
*Administration*	•	Uses basic knowledge in the policy, organization, and financing of health care and case management systems
	•	Uses tools under the supervision of a graduate level to collect data for assessing clinical, financial, humanistic/satisfaction, quality, and functional outcomes for patients, families, disease management populations, and communities
	•	Participates in case or disease management systems
	•	Participates in Continuous Quality Improvement (CQI) programs
*Education*	•	Participates in professional organizations and staff development programs related to case management
	•	Maintains certification as case manager

F. Several graduate programs in nursing focus on case management as a specialty at the graduate level of nursing practice. There are also programs that combine nursing and social work with a focus on case management.

TABLE 13-2 Case Management at the Advanced Practice Level: An Overview of the Role of the Case Manager

Aspect	Content
*Practice*	•	Uses advanced knowledge of pathophysiology
	•	Uses advanced health assessment skills
	•	Synthesizes theories from natural, behavioral, social, and applied sciences to support advanced practice and role development for case management
	•	Uses community development and intervention processes to design, implement, and evaluate health promotion and disease prevention programs for patient populations and communities
	•	Collaborates with providers and consumers in designing, implementing, and evaluating innovative health programs and community services for patient populations
	•	Assumes accountability of ethical values, principles, and personal beliefs that acknowledge human diversity and influence professional practice decisions and nursing interventions
	•	Designs and administers quality case management services at the individual, disease management, and/or community level
	•	Designs case management systems that address human diversity and social issues
	•	Becomes “expert” generalist in terms of dealing with health care issues
	•	Provides leadership in coordinating, managing, and improving health programs and health services to culturally diverse individuals and populations
	•	Develops and/or accesses evidenced-based practice guidelines
*Research*	•	Initiates research to address case management issues and practices in rural areas
	•	Acts as a consultant to other researchers and providers regarding case management
	•	Provides research consultation to members of multidisciplinary team on all aspects of case management for patient populations
	•	Supervises interdisciplinary research on case management requirements for patient populations
	•	Develops research proposals for external funding
	•	Assesses and accesses preexisting data bases to facilitate case management processes at all levels
	•	Contributes through research to elaboration of case management conceptual frameworks
*Administration*	•	Uses advanced knowledge in health policy, organization, and financing of health care and case management systems to design, coordinate, and evaluate case management systems
	•	Designs cost-effective intervention/strategies collaboratively with multiple disciplines to provide quality health care for patient populations
	•	Assumes leadership in professional role definition and development for case managers
	•	Develops informational and organizational systems for assessing clinical, financial, humanistic/satisfaction, quality, and functional outcomes for all levels of case management within patient populations
	•	Designs, implements, and evaluates methods for efficient and effective use of human and material resources to support case management services
	•	Organizes and evaluates case management systems
	•	Organizes CQI programs that address unique characteristics of case management
	•	Advocates for patient populations in policy formulation, organization, and financing of health care
*Education*	•	Acts as a facilitator and mentor to advanced practice case management students
	•	Serves as case management expert for staff development processes in area of rural case management
	•	Provides leadership in professional organizations
	•	Educates consumers and health care professionals about the role of case manager
	•	Provides leadership in the design, implementation, and evaluation of education for patient populations
	•	Disseminates research findings at professional meetings