Is case management evolving into a true profession?
Case management field experiences birthing pains
As fledglings, other professions have experienced the same growing pains that case management now experiences. There comes a time in any discipline when its practitioners suddenly realize they possess skills and knowledge distinct from other disciplines. Practitioners demand certain requirements of individuals who wish to join the group. From these realizations comes the establishment of a new profession.
Case management is a multidisciplinary field. For years, the argument has been that because of this multidisciplinary aspect, case management is an advanced practice rather than a true profession. There are indications, however, that case management has entered a historic new phase in its development. As the development process continues, only time will reveal whether case management emerges as a true profession and puts aside the label "advanced practice." (For further discussion of the evolution of case management, see column on p. 204.) "This is a very complex phenomenon. It’s not as if society one day stands up and says, Hey, you are professionals, and we will call you case managers.’ It starts with a group distinguishing itself from commercial activity," says Mark E. Meaney, PhD, health care ethicist for the Center for Health Care Ethics at the St. Joseph’s Health System in Atlanta. "Society through a variety of means, whether it be recognition of a formal education and accreditation process, through legislation, or through the courts, begins to recognize this group as a profession," he notes.
The legal route
In fact, Meaney reminds case managers that it was a lawsuit earlier in this century that moved nursing into a profession. "A nurse was ordered by a physician to administer a drug. The drug ended up killing the patient, and the nurse, not the doctor, was held responsible by the court," says Meaney. "The judge told the nurse she should have known better. That was the first forceful acknowledgement of the distinctive nature of nursing. It marks the moment when nurses became more self-conscious in distinguishing themselves from physicians and became a profession."
At times, government appears to legislate a group into a professional presence. For example, in many states individuals must hold specified credentials to practice specific case management activities. "In Florida, to work as a case manager in workers’ comp, I must have my CDMS [certified disability management specialist]," says Kathleen Moreo, RN, BSN, BPSHSA, CDMS, ABDA, co-owner of Professional Resources in Management Education, in Miramar, FL. "As case managers, we stand at the core of a case and take pot shots from all sides. It’s important to have someone to stand tall with," notes Moreo. "It’s important to belong to a practice with commonalities and ethical statements and standards of practice."
A certification process is an essential step in professional development, says Meaney. If this is true, case management is definitely in the throes of change with two new certification processes in two years in addition to several long-established certification exams. (For a full discussion of case management certification exams, see Case Management Advisor, January 1997, pp. 1-6.)
The certification route
"Certification systems must recognize the changing needs of health care systems and the needs of nurses building careers within those systems," says Carolyn K. Lewis, RN, PhD, director of the American Nurses Credentialing Center (ANCC) in Washington, DC. "As the 21st century approaches, nurses must add clusters of competencies as their roles and responsibilities evolve to match the needs of the health care system. ANCC recognized this paradigm shift in health care delivery and responded to the nursing community by developing a certification examination in case management."
The ANCC launched its case management certification exam for nurses with a pilot test in October. Roughly 500 applied to sit for the pilot and an estimated 300 actually did, according to ANCC. Although the October exam was a pilot, nurses who passed the exam will be certified, says Lewis.
The ANCC was so flooded with demands for its October exam period that many case managers who requested information about and applications for the exam did not receive a response from ANCC in time for the October exam. "More than 22,000 nurses applied for our October exams," says Lewis. The flood of applications was caused by an advertised implementation of a new baccalaureate degree requirement for ANCC generalist exams. Nurses without their baccalaureate degree wanted to receive their generalist certifications before the January 1998 cutoff. After January 1998, nurses must have a baccalaureate to sit for any ANCC generalist exam. "Since 1992, any new exams, including the case management exam, require that nurses have their baccalaureate. However, for exams developed prior to 1992, this was not always the case," notes Lewis, adding that she would rather not provide specific details about eligibility for the ANCC case management exam because the requirements were undergoing review. (For a look at material covered on the exam, see chart on p. 203.)
The ANCC was buried under the weight of the 22,000 applications and couldn’t adequately respond to all inquiries about the new certification, says Lewis. "We’re sending out a note of apology to those who requested applications and didn’t receive them," says Lewis. "We try very hard to be customer service-oriented."
The Center for Case Management in South Natick, MA, has developed yet another new case management certification. Although the process is still under development, a senior consultant at the center confirmed that the certification exam is designed for directors of case management and that an information packet on the certification will be available later this month.
The development of professional associations and certification processes are essential steps on the road to becoming a profession, notes Meaney. If this is true, then a baby step of historic proportions took place in Chicago in mid-October when representatives of case management and care management associations and credentialing commissions met for two days of discussions.
"The intent was to see if the organizations represented, all of whom have an investment in care or case management, could develop a consensus of what it is, how and where it is practiced, and by whom, so we can better educate consumers, funding sources, the government, and anyone else with an interest in the field," says Rona Bartlestone, MSW, LCSW, BCD, CMC, president and CEO of Rona Bartlestone Associates in Fort Lauderdale, FL, and co-chair of the national Academy of Certified Care Managers (NACCM) in Hollywood, FL.
Sixteen organizations sent representatives to the Chicago meeting organized by the National Association of professional Geriatric Care Managers and the Foundation for Rehabilitation Education and Research in Rolling Meadows, IL. A total of 35 individuals represented those organizations, which included:
• the Case Management Society of America (CMSA) in Little Rock;
• the Commission for Case Manager Certification in Rolling Meadow, IL;
• the NACCM;
• the Health Insurance Association of America in Washington, DC;
• the National Association of Social Workers in Washington, DC;
• ANCC.
The objective of the meeting was to generate a position paper to be published in early 1998. The position paper will include a consensus on the following issues:
• definitions of care and case management;
• respective domains of care and case management;
• core and advance certification needs for care and case management.
The organizations agreed to meet again and eventually hope to develop a consensus report that defines care and case management. "There are several issues we’d like to address," notes Bartlestone. "For example, there are now a multiplicity of credentialing bodies. Each has its own different eligibility criteria which makes the area of care and case management credentialing fragmented and confusing for consumers and other interested parties. Our hope is to develop a better definition of the field in total."
The ties that bind
"With care and case management coming from a number of disciplines, the whole issue of uniform definition of role and function has finally come to a point where it has to be addressed in order to move the process, or profession, along," adds Cheryl M. Whitman, MSN, CMC, director of the Case Management Institute of Connecticut Community Care in Bristol. "With the growth of care and case management, and the market use of care and case management in managed care, there is a huge influx of individuals calling themselves care and case managers. It’s time for the various interested organizations to work together to bridge any gaps and collaborate on a shared definition and ethical issues."
"It’s very difficult to effectively manage a case, when the people within the case framework don’t have a clear understanding of who a case manager is and what a case manager does," says Mary F. Gambosh, RN, CDMS, CCM, president of Mary F. Gambosh Limited, a case management consulting firm in Richmond, VA, and past president of CMSA. "We’re hoping that we can move together and try to end some of the fragmentation in case management. Instead of focusing on differences between care and case management and the various certifications, we’re trying to look at similarities."
Education, certification, and professional ethical development are imperatives of a true profession, notes Meaney. "The goal or aim of case management is service to the public interest and that societal function is one these organizations must not lose sight of," he says. "There has been an increase in the number of undergraduate courses in case management that recognize the specialized nature of case management and the level of skill required. Formal education serves as a foundation for certification. Certification is essential to professional development. Whether all of this activity leads to professional autonomy, and whether the final impetus comes from the legislative process, the courts, or the professional organizations themselves, is yet to be determined," says Meaney.
[Editor’s note: For more information about the new Center for Case Management certification, contact the center at: 6 Pleasant St., South Natick, MA 01760. Telephone: (508) 651-2600. Fax: (508) 655-0858. For more information on the American Nurses Credential-ing Center (ANCC), contact: ANCC, 600 Maryland Ave. SW, Suite 100 W, Washington, DC 20024-2571. Telephone: (800) 284-2378. Fax: (202) 488-8190. Look for a full discussion of case management education and training opportunities in a future issue.]
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