States put case managers’ clinical qualifications on trial
New Hampshire reverses denials, but other states likely to follow with their own suspensions
New Hampshire may have been the first state to take a hard line on renewing the RN licenses of hospital case managers, but it’s not likely to be the last, experts warn.
The New Hampshire controversy began late last year, when the state board of nursing in Concord denied the renewal applications of two nurse case managers in what it claimed was a quality control measure designed to protect health care consumers. (See "New Hampshire CMs denied RN license renewal," Hospital Case Management, October 1999, p. 173.) Recently, the nurse case managers, who work for Blue Cross Blue Shield of New Hampshire in Manchester, successfully appealed the ruling and won relicensure. But some say the larger battle — over whether case managers’ duties are sufficiently clinical to warrant the RN credential — is just beginning.
Sandra L. Lowery, BSN, CRRN, CCM, president-elect of the Little Rock, AR-based Case Management Society of America, says that even though the New Hampshire decision was reversed, "it remains the policy of that state’s board that if a case manager’s job description can be performed by someone other than a nurse, it is subject to not meeting the board’s eligibility requirement. No one had brought a problem of relicensure to our attention until last fall. I have a concern that other states might follow New Hampshire’s lead," says Lowery.
Indeed, Susan Woodward, director of communications for the National Council of State Boards of Nursing in Chicago, says New Hampshire’s minimal practice stance is not unique. "A minimal practice standard for RN license renewal is required in 21 of our 61 jurisdictions," Woodward notes. Delaware, Maryland, and New Mexico require that an RN be actively involved in the practice of her profession for 1,000 hours in the past five years; Guam requires four months in the past two years; and North Dakota requires 500 hours in the past five years.
But Lowery claims that, by themselves, minimum practice requirements are not the problem. "Other states do have the requirement for work experience. That is not the point of contention. The problem is New Hampshire’s criteria for eligibility for work experience, and that is unique: The state board’s policy is that if a case manager’s job description can be performed by someone other than a nurse, it is subject to not meeting the board’s eligibility requirement."
The New Hampshire board does not see any problem with a case manager holding a nonclinical position as long as she uses her nursing knowledge and experience to perform the work. But it does consider it a problem if the job that the case manager uses for her work experience eligibility can be performed by non-nursing personnel.
Toni Cesta, PhD, RN, director of case management at Saint Vincents Hospital and Medical Center in New York City, says part of the problem is that case management as a field still isn’t well-defined. There’s a wide variation today among people who call themselves case managers and among the duties they’re required to perform. "There’s a trend toward a clinical focus in case management, but it’s not across the board," Cesta says. "We can’t generalize on how much of a clinical background a case manager should have. It depends on where she works."
What makes the issue of licensure so difficult is that case management is a multidisciplinary practice by design, Lowery maintains. "Some hospital case management positions can be performed by social workers, and that could be a problem. There could be problems lying in wait for nurse case managers who are working in jobs that could be performed by someone other than a nurse. The issue is not solved."
L. Greg Cunningham, president of the American Case Management Association (ACMA) in Little Rock, AR, says his organization supports "an integrated case management model which uses professional collaboration across disciplines. However, this does not mean that everyone is or should be performing the same job functions. The intent of a collaborative model is the ability to leverage the skill sets of multiple disciplines. In acute care case management, these disciplines are primarily registered nurses and social workers. ACMA’s board can also attest that RNs who are performing in an effective’ model of case management cannot function without using their clinical skills and therefore would adequately meet active clinical practice requirements."
Even the issue of what credentials case managers should hold is up in the air at many institutions. Cesta points out that some facilities hire baccalaureate-prepared case managers regardless of what their degree is in, while others hire only nurse practitioners. Cesta advocates having a master’s of nursing in case management. Currently, about 30 programs in the country offer this degree. "But you can get a job without a master’s," says Cesta. "There’s a trend toward employers looking for some kind of certification in case management, but if you have an advanced degree, you usually don’t need certification." Conversely, if you don’t have an advanced degree, certification is probably necessary.
Cesta is a commissioner for the Commission for Case Manager Certification in Rolling Meadows, IL, which offers the Certified Case Manager (CCM) credential. You don’t need an RN to get a CCM certificate — you can be a social worker. The case management certification offered by the American Nurses Association is a baccalaureate-level credential, and you don’t need a master’s, but you do have to have an RN, as you do for any ANA certification.
"There’s such a lack of standardization across the industry that it’s very difficult," Cesta explains. "You can sign up for a three-day class, at the end of which you get a certificate from a number of companies. That certificate should not be confused with certification. A certificate like that is by no means as robust as certification."
Darlene Saler, RN, acting director of case management at Dartmouth-Hitchcock Medical Center in Lebanon, NH, says some of her 11 case managers are RNs and some are social workers, depending on the patients they manage. The social workers work with patients with psychosocial issues; the RNs handle patients with clinical issues, and they do disease management.
"Our response to the relicensing issue is that we are going to revise our job descriptions and be very clear on the divisions between social worker and RN. We’re going to have to be very clear on the differences," Saler explains. She says at first she didn’t understand why New Hampshire’s nursing board made its initial decision, but now she does. "At first I was outraged, but now that I understand their position, it is reasonable. They are looking closely at what people are doing and making sure it’s what they should be doing. The nursing board is making sure the skills required of a nurse are unique skills that nobody else can do. It’s a reasonable stance," she says.
Saler says the nursing board is being asked more and more about what constitutes nursing care. It is dealing with several related issues right now and trying to come up with fair solutions. "For example," says Saler, "what do you do with a nurse case manager who is taking care of a family member in her home? She’s not working outside the home, but technically she’s using her nursing skills. Does she qualify for relicensure? Are the unique skills of the nurse required for that job? Can anyone else do that? Can those hours spent working at home taking care of a family member count toward the minimum practice eligibility requirement? That’s what they are struggling with."
Saler says that from now on when she hires people as case managers, she will make clear what skills those individuals need for the job. "When I hire my case managers, before I even post the position, I will know whether I need a nurse or a social worker, based on the population she will be asked to manage. I need to fix my job descriptions to reflect that I’m hiring different people for different jobs."
Will other states follow New Hampshire’s lead? Saler says she has talked with case managers working for health plans in neighboring Vermont. "They are beginning to think about being careful about asking a person to do particular tasks that you would ask a nurse to do."
Choose jobs with relicensure in mind
Jackie Soroko, RN, a nurse case manager at Greenbriar Terrace Healthcare in Nashua, NH, has some advice: No matter where you do your nursing case management — in a hospital or for an insurance company — you’re always assessing the patient, you’re always formulating and putting a care plan into action, you’re always monitoring that care plan, and you’re always re-evaluating it on a regular basis. Those are all nursing functions. If you want to qualify for RN relicensure, make sure you do those functions in the job you take.
"If you are working as a nurse case manager for an insurance company, that is a nursing position," Soroko says. "It’s no different from acting as a nurse manager in a hospital." She says when she was director of nursing for eight years, even though she may not have used her skills, "I sure used my knowledge every day."
In nursing case management, you use your knowledge every day, every time you look at a patient. "I think it’s important for the board of nursing to remember that, and to realize that those are functions of any nursing case manager," she says. There are case management positions where social workers can fill the role, especially in mental health, and that’s appropriate, she notes. "If I took a job like that, I may not expect to be relicensed; it depends on what my function would be." She says she personally wouldn’t want to take a job of that description because she wants to use her skills and continue to maintain her license.
For more information, contact:
Sandra L. Lowery, BSN, CRRN, CCM, independent case manager; president, Consultants in Case Management Intervention, Francestown, NH; president-elect, Case Management Society of America, Little Rock, AR. Telephone: (603) 547-2245.
Susan Woodward, director of communications, National Council of State Boards of Nursing, Chicago. Telephone: (312) 787-6555, ext. 165.
Toni Cesta, PhD, RN, director of case management, Saint Vincents Hospital and Medical Center, New York. Telephone: (212) 604-7992; e-mail: tcesta@ saintvincentsNYC.org.
L. Greg Cunningham, president, American Case Management Association, Little Rock, AR. Telephone: (501) 907-2262; e-mail: [email protected].
Darlene Saler, RN, acting director of case management, Dartmouth-Hitchcock Medical Center, Lebanon, NH. Telephone: (603) 650-8328.
Jackie Soroko, RN, nurse case manager, Greenbriar Terrace Healthcare, Nashua, NH. Telephone: (603) 891-0110.
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