1. Muller, Lynn S. RN, BA-HCM, CCM, JD

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Did you ever walk into a medical practice for yourself or with a case management client and were greeted by a charming man or woman dressed in a white uniform? You identify yourself or the patient and provide personal information without question because of the environment. Did you ever stop to ask that person, when they later took a blood pressure or asked about current symptoms and complaints or medical history, what the individual's title was? Are you dealing with a nurse, medical technologist, physician's assistant, or simply a high school graduate, if that? Would you open your mouth without being sure that the person with the drill in hand is really a dentist?


You know it when you see it; a lead story on the nightly news about an individual arrested for impersonating a medical doctor (MD), perhaps even performing surgery. This criminal defendant has violated a variety of state laws and endangered patients, but what about the individual who by choice or by employer directive puts on a name tag that says, "Case Manager?" For me, that representation of a professional identity starts a stream of duties, responsibilities, and obligations, including adherence to the Standards of Practice for Case Management and Ethical Codes, as well as lawful compliance with a state practice act for the underlying profession under which the case manager is licensed, such as a physician, nurse (registered nurse [RN]), social worker (SW),1 therapist, and so on. The laws that limit who can call themselves physicians, nurses, SWs, and therapists are what is referred to as "title protection." The most common reference is "holding oneself out," which means that an individual is using either the name or commonly understood initials (i.e., MD, RN, APRN, SW, PT). It is not about protecting one's turf, it is all about protecting the public.


What Is Title Protection?

Title protection is the limitation on who can say, "I am a doctor or MD, I am a nurse (RN, NP, APRN), or I am a social worker (SW, LCSW). More specifically, when individuals presents themselves to the public as a RN, MD, SW, or other health care professional who must be licensed and meet minimum legal and professional standards, they are broadcasting to the public that they [the public] can rely on and feel safe in their "hands" and expect a certain level of care. Ethical practice is guided by the framework of laws and regulations, along with Codes of Ethics and Standards of Practice. With the possible exception of statutory mandates, no one of these elements stands alone. Title protection also encompasses both the law and professional standards. As health care professionals, it is incumbent upon us to take an active role in the future of professional case management.


What's in a name? Displaying a title on a name tag or stating "I am a ___" implies that the patient can rely on the wearer's representation and therefore feel comfortable in sharing signs, symptoms, intimate information, and anything else that relates to his or her life and the reason for being in treatment or needing treatment. The client is placing herself or himself in a vulnerable position that can affect his or her health, home life, employment, and his or her future. It means that the wearer has completed the requirements to call himself or herself MD, SW, RN, and so on. So what of the high school graduate or licensed vocational nurse (LVN) who is hired by an insurance company or medical center and told by the employer that he or she is now "a case manager"?


What Does Our Professional Foundation Say?

When addressing professional case management, we must first acknowledge that we encompass many health professions. Each profession licenses its practitioners based on mandatory educational achievement, as well as practical experience and a standardized assessment of the individual's ability, typically through an objective examination. The qualifications for a professional case manager are no different. At a minimum, a "current, active, and unrestricted licensure or certification in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline" (Case Management Society of America [CMSA], 2010, p. 19); the key word is "independently." The practice of nursing is statutorily mandated by the Nurse Practice Act in the state(s) in which the nurse is licensed to practice and requires specialized knowledge, skills, and independent decision making (Nurse Practice Act of 2011).


Individuals are required to have a license to practice as a nurse. Licensure authorizes a legal scope of practice for a nurse, provides legal use of a title, and includes standards of practice ... this initial licensure provides the legal scope of practice for the Registered Nurse. (Chornick, 2008, p. 80)


Specialty Practice

Under the general category of a recognized profession, there are subspecialties. For example, an MD might also be a board certified pediatrician, certified by the American Board of Pediatrics, or orthopedic surgeon, certified by the American Board of Orthopedic Surgery, so too with case management. Case managers can be board certified by the Commission for Case Management Certification (CCMC).


Board certification is your next step in professional growth and advancement. The Certified Case Manager (CCM(R)) credential is the gold standard, demonstrating your knowledge, expertise, skills and ability to practice competently. Board certification encourages accountability and ensures consumer protection is your highest concern. It underscores your ability to work effectively on today's multi-disciplinary team environment. (CCMC, 2016, p. 1)


There are more than 37,000 board certified case managers practicing today (CCMC, 2016). Evidence to support the value of the professional case manager is well documented, and there has been recognition that through transitions of care, multiple case managers direct and coordinate necessary care for the changing needs of the client (Nalley, 2012).


What Would You Do?

You are an LCSW or an RN licensed to practice independently in your state. You have been working for 2-3 years as a case manager. In addition, you invested your time, spent your money (perhaps including a review class), and studied long and hard to first qualify for consideration and then sit for the CCM examination. Congratulations, you passed! You now have the privilege of calling yourself a CCM and are newly bound by the CCMC Code of Professional Conduct for Case Managers in addition to the CMSA Standards of Practice for Case Managers.


Soon after, you are called to the C-Suite, where you meet with the chief nursing officer, the chief financial officer, managers, and others. You are told that because of your recent achievement, you are being promoted to Director of Case Management. Then you are told that the case management staff that you will be responsible for is made up entirely of LVNs and highly motivated high school graduates. Both groups will be provided with "on-the-job case management training" including learning modules. You quickly realize that you are alone and that the entire staff must be directly supervised by you, the only one with the title professional case manager and the credentials, education, and experience to support that title. None of your staff has the ability to practice independently and you are potentially liable for all their actions, omissions, and errors. There is no simple answer to this scenario.


The problem is who will conduct assessments? Even with sexy high-tech tools and checklists to assist with assessments, the practitioner who uses the tool must interpret the information collected and that requires independent assessment by a professional. The ability to conduct an independent assessment is beyond the scope of practice for an LVN and certainly not appropriate for an unlicensed support staff (aka: paraprofessionals). Interestingly, the use of the title "paraprofessional" comes from education and is a term used for a person assigned tasks and supervised by a licensed classroom teacher. After 2006, such individuals are required to secure additional education, including college degrees, if they are to use the title (United Federation of Teachers, 2006).


If you are in a 40-bed hospital and the staff consist of two to three LVNs, it is likely that you could provide the requisite direct supervision that is essential and delegate other functions appropriately. But what do you do when you work for a multistate company or a large medical center. No individual, no matter how well trained and experienced, can take on the responsibility for direct supervision of hundreds of staff members. For professional case managers to gain and maintain respect and acknowledgment of our unique value, it is essential that we self-regulate and not passively except corporate or hospital mandates. We have a duty to advocate for our patients, ourselves, and our profession.


Title Protection Today

The practice of medicine and nursing has become vast and complex. If you ask a question about title protection, your query may result in no fewer than 50 state answers, as well as U.S. Territories. In Ohio, for example, there is a vividly clear statute that defines who may hold themselves out to the public as a nurse, by name or initials (see Table 1). This law makes it very clear that the person who calls himself or herself nurse and advanced practice nurse must meet licensing requirements (Ohio Administrative Code, 2015).

Table 1 - Click to enlarge in new windowTABLE 1 4723-8-03 Title Protection

In the state of Washington, the State Supreme Court held that:


Physical therapy is one aspect of the practice of medicine. The practice of medicine is defined by RCW 18.71.011(1) as "[o]ffer[ing] or undertak[ing] to diagnose, cure, advise, or prescribe for any human disease, ailment, injury, infirmity, deformity, pain or other condition, physical or mental, real or imaginary, by any means or instrumentality." This broad definition readily encompasses all the acts constituting the statutory definition of the practice of physical therapy. (Ridgeway, 2012, p. 1)


The Commonwealth of Virginia went so far as to enact a law limiting language in physical therapy advertising:


It shall be unlawful for any person who is not licensed under this chapter, or whose license has been suspended or revoked or who licensure has lapsed and has not been renewed, to use in conjunction with his name the letters or words "R.P.T.," "Registered Physical Therapist," "L.P.T.," "Licensed "Physical Therapist," "P.T.," "Physical Therapist," "Physio-therapist," "P.T.T.," "Physical Therapy Technician," "P.T.A.," "Physical Therapist Assistant," "Licensed Physical Therapist Assistant," or to otherwise by letters, words, representations or insignias assert or imply that he is a licensed physical therapist. The title to designate a licensed physical therapist shall be "P.T." (Code of Virginia, 2010)


This is an example of comprehensive title protection.


In North Carolina, SWs are expressly protected, but it is made very clear who can call themselves "social worker." [S] 90B-16 of the General Statutes is titled, "Title Protection," and it states (a) except as provided in G.S. 90B-10, an individual who (i) is not certified, licensed, or associate licensed by this Chapter as a social worker, (ii) does not hold a bachelor's or master's degree in social work from a college or university having a social work program accredited or admitted to candidacy for accreditation by the Council on Social Work Education, or (iii) has not received a doctorate in social work shall not use the title "social worker" or any variation of the title. It then goes on to identify the Board of Social Work as the entity authorized to enforce title protection. N.C.G.S. 90B-13 (NASWNC, 2010). It is not up to us, case managers, to solve the struggles within any of the professions who come under the case management umbrella. It is our role to help give direction to those who seek to rise to the level of professional case manager. Title protection for a particular underlying profession is important and improving educational and practicum requirements raise the bar for all.


What Can We Do?

Through participation in state and national professional associations, health care practitioners can keep up to date and identify advocacy opportunities to advance their underlying profession, as well as uniting with the voice of professional case management. The Case Management Society of America, the professional association "dedicated to the support and development of the profession of case management" (CMSA, 2016, p. 1), has been spearheading the advancement of professional case management. Through the creation of the Case Management Model Act (the Model Act), CMSA has provided federal and state legislators a foundation for crafting legislation while maintaining patient-centered case management practice standards. The Model Act is available at:, as well as other resources, including a sample letter that you can send to your Senators and Representatives in Congress. These and other resources are available on the CMSA website. Participation in the public policy activities of CMSA and/or your professional association places you center stage to ensure the future and quality of professional case management services to your clients and our country.


Through collaboration with colleagues within and outside other professional associations, such as CCMC, the National Association of Social Workers, and the American Nurses Association, the path to consensus for professional case management has advanced farther than ever before. This ongoing effort to define and clarify who can be called "case manager" has the potential to impact health care delivery in the future.


What Does the Future Hold?

Current trends, in a variety of practice settings, appear to be a move to imbed those who have not acquired the education and training necessary to call themselves professional case managers. This is a stellar example of cost saving at the expense of patient safety and quality care. Are there some "tasks" that can be performed by a "paraprofessional"? Perhaps, but the role of the professional case manager utilizes a wealth of knowledge acquired through advanced education and years of practical experience. It is that global knowledge base that empowers professional case managers with a comprehensive ability to assess, not only physical signs and symptoms but also how the presenting illness and/or injury will impact treatment choices and the client's life going forward. A name tag does not a case manager make.




Commission for Case Management Certification. (2016). Professional case manager. Retrieved from Commission for Case Management Certification website:[Context Link]


Chornick N. (2008). Ethics and regulation. JONA'S Health Care Law, 10(4), 90-93. Retrieved from[Context Link]


Case Management Society of America. (2010). Standards of practice for case management. Little Rock, AR: Case Management Society of America. [Context Link]


Case Management Society of America. (2016). Who we are. Retrieved from Case Management Society of America website:


Code of Virginia [S] 54.1-3481 (2010). [Context Link]


Fink-Samnick E. (2016). Protection for professional case management: Social work's intricacies and opportunities. Professional Case Management, 21(4), 201-206. [Context Link]


Nalley C. (2012, August). Evidence-based case management. Retrieved from Advance Healthcare Network for Nurses website:[Context Link]


NASWNC. (2010). Title protection in North Carolina. Retrieved from[Context Link]


Nurse Practice Act, N.J.S. 45:11-26 (2011). Retrieved from[Context Link]


Ohio Administrative Code. (2015). Advanced practice certification and practice. Retrieved March 21, 2016, from[Context Link]


Ridgeway K. (2012). Term & title protection for the #physical therapist & #physical therapy. Retrieved from PT Think Tank website:[Context Link]


United Federation of Teachers. (2006, April 1). Qualification requirements for employment as full time educational paraprofessionals. Retrieved from the United Federation of Teachers website:[Context Link]


1 For the purpose of this article, reference to social workers will be limited to "social worker (SW)" and licensed clinical social worker (LCSW). For a complete discussion of "Title Protection" from the viewpoint of SW, see Fink-Samnick (2016). [Context Link]