Are you meeting URAC’s CM standards?
CM accreditation reviewer walks you through
If your organization hasn’t yet applied for accreditation of its case management program through the American Accreditation Healthcare Commission/URAC in Washington, DC, consider this: URAC launched its accreditation program for utilization management organizations 10 years ago, and now 20 states have adopted or modeled their utilization management legislation after the URAC standards.
"When we develop standards, we’re not just creating quality benchmarks, but we’re defining the parameters of how case management organizations should function," notes Gary Carneal, JD, MA, president and chief executive officer of URAC. "Meeting accreditation standards today may help your organization meet state statute requirements tomorrow."
The case management organization accreditation was launched last year and initially received some criticism for being too stringent, especially in the areas defining qualifications for case managers and supervisors of case management, says Sue Ohr, MSHS, BSN, RN, RN-C, an accreditation reviewer for URAC’s case management organization accreditation program. "The goal of case management accreditation is to set some nationally recognized standards for the structure and practice of case management. We want to also raise the bar and ask organizations to continue to improve the quality of their services," she says.
The 33 case management standards are divided into 23 "shall" standards, which must be met, and 10 "should" standards, which organizations should strive to meet, Ohr says. Organizations must meet 100% of the "shall" standards and 60% of the "should" standards to receive full accreditation, she says, adding that most of the "should" standards center around the highly contested issue of case manager qualifications.
The standards are broken down into two general categories — structure and organization, and the case management process. As she travels around the country conducting accreditation reviews, Ohr notes common problems among case management organizations.
"We want to see that an organization has policies and procedures that govern all aspects of the case management process," says Ohr. "We want to see a well-written and developed mission statement. We want to see that there is clearly identified organizational oversight. We want to know that your case management definition is the same as URAC’s. We also want to know who is responsible for the case management quality process."
Specific elements that URAC requires case management organizations to identify include descriptions of the case management delivery model, telephonic or on-site; how the caseload is assigned; and the medical advisor.
"If I knew the best way to assign case management caseloads, I could retire from URAC," she says. "What we want to know is that you have a clearly identified number . . . you can evaluate that is based on a clearly defined rationale such as severity rating. We also want to see that you have an adequate number of staff members to care for your population."
URAC does not require case management organizations to have a full-time medical director, but it does require them to have a qualified clinician whom case managers can access when they have questions.
When the standards were first presented for review, case management staff qualifications were hotly disputed, Ohr says. The URAC standards were revised somewhat in response to public comment that they were too tough to meet. Currently, supervisors of case management must have at least a bachelor’s degree in a health-related field, some type of licensure or certification in a clinical specialty, and at least five years of case management experience. In addition, the URAC standards require that if you have been a supervisor in an organization and held that position for at least three years, you should have a certification as a requirement of your job.
Creating lifelong learners
URAC requires case managers to have at least a bachelor’s degree in a health-related field and licensure or certification in case management, or they must be an RN with at least three years of clinical experience.
Currently, URAC recognizes eight certifications as appropriate for case management. If you have a certification that is not on URAC’s approved list, you can appeal, notes Ohr. "We invite you to provide certain information when you submit your application in order to have your certification recognized. To be recognized, a certification must be part of a validated and recognized program that is research-based. In addition, the certification must be at least partly based on passing an exam."
URAC also requires case management organizations to have a job description for case managers that identifies the qualifications expected, and an annual performance evaluation. "We also require organizations to have a full orientation process for staff and that they provide proof of the effectiveness of that training," says Ohr, adding that organizations also must provide ongoing and relevant professional education for staff.
"Some organizations we’ve accredited actually reimburse staff for license renewals and certification processes or certification prep courses," she says. "One best practice we identified was an organization that formed its own chapter of the Case Management Society of America in Little Rock and allowed staff to hold meetings on site during the lunch hour."
Two areas that cause problems for case management organizations during their accreditation reviews are information management policies and procedures, she says. "We look at how you maintain patient confidentiality. We look closely at the care and storage of your records. Are you shredding your records after seven years, or do you contract with a vendor who disposes of old records properly?"
URAC also requires organizations to have a policy regarding the ethical use of patient data. "We want to know that data is used in the aggregate for outcomes measurement," she explains.
Although the standards require organizations to have a grievance process and track the grievances, she encourages case management organizations to track their compliments as well. Potential clients often ask about past customer complaints. "Wouldn’t it be nice to say, I have that information, but I also have information on the number and types of compliments our staff has received.’ It’s a wonderful way to market your services," she notes.
Measuring effectiveness
URAC requires case management organizations to have a quality improvement process that evaluates the effectiveness of an organization’s case management services. Measures URAC looks for during accreditation reviews include disease management outcomes, cost-savings outcomes, utilization of resources, availability of care, effectiveness of preventive care, and cost of care.
Oversight of delegated functions and disclosure of information to patients regarding the case management services also have caused problems during the review process. "If you subcontract any of your services, you must have a written contract with subcontractors, perform periodic review of their policies and procedures, and monitor their performance," Ohr notes.
However, the standard that most organizations have trouble implementing is the disclosure of information standard, says Ohr. "Usually, when I do a desktop review, most organizations state they have a policy for disclosing information about their services to patients, but when we go on site and evaluate, we find there’s no documentation to support that statement."
URAC requires patients to be informed at the onset of case management services about the nature of the case management relationship. "As a best practice, what I’ve seen work best is a letter of introduction that is sent to the patient prior to case management service. If, as an organization, you don’t feel that a letter of introduction will work for you, you must have a system for documenting verbal disclosures."
Information Ohr says must be disclosed to the patient includes the circumstances in which you will release information to third-party payers; how and when the patient will receive written notification of the care plan; the complaint process; and the rationale for the case management service, or why the patient was selected for case management. Of course, URAC also requires organizations to receive consent from patients before beginning case management services. "We want to see documentation of the patient’s oral consent to case management services and a preference for receiving written consent," she says. "That consent must be explicit."
Another area that seems to cause problems for case management organizations is the plan of care standard, she says. "We find [that] many organizations fail to meet the full standard. You must have a short-term and a long-term goal and time frames for response to your interventions. You have to identify which resources you are going to use. You also have to clearly establish the criteria for case closure." In addition, there must be a written policy for conflict resolution. "Do you know how you are going to resolve differences, if the supervisor disagrees with the case manager’s care plan?" Ohr says.
One of URAC’s goals is to establish that case management remain patient-centered. "We look closely at patient access to care," says Ohr. Questions you may be asked by a reviewer include these:
• Do you have a toll-free number?
• Do you have a collect call system?
• Do you have a process in place for timely call backs?
"Our objective is to evaluate the program’s ability to deliver high-quality services. It’s a way to identify for purchasers of case management services that your organization has met a published set of standards and to state and federal regulators that your organization promotes outcomes measures and management through accountability," says Ohr.
[For additional information, including a list of accepted certifications, contact: American Accreditation Healthcare Association/URAC, 1275 K. St. N.W., Suite 1100, Washington, DC 20005. Telephone: (202) 216-9010. Fax: (202) 216-9006. Web site: www. urac.org.]
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