1. Lattimer, Cheri BSN, RN
  2. Powell, Suzanne K. MBA, RN, CCM, CPHQ

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The important thing is not to stop questioning. - -Albert Einstein


In the September/October Editorial, we broached the topic of asking the right questions. Perhaps it is because 2009 has been such a year of healthcare change that this theme of asking the right questions continues in the last two PCM journal issues. And besides, who are we to question Einstein who said, "The important thing is not to stop questioning"? Last PCM issue, we said, "In case management, asking questions is important; but formulating the right question is imperative." This takes skill, creativity, and a healthy dose of intuition. By their very nature, questions are born from the unknown.


By asking the right question, life can change at an exponential rate. Consider healthcare history: "What if healthcare workers washed their hands? What happened in the 1800s?" This question was unacceptable at first; it was inconceivable that physicians could be responsible for passing disease and causing death of their patients? Lister and others have since proven this to be not just a possibility but also a fact. Almost 150 years later-and more than a century after Lister, Pasteur, and most physicians accepted the germ theory of disease, the U.S. Centers for Disease Control and Prevention concluded that hand washing is "the single most effective way to prevent the transmission of disease." But, alas, in 2009, healthcare is still struggling with the hand-washing issue (Kihlstrom, 2009).


Here is another well-placed question that changed the lives of humanity. "Why are all these people dying when receiving blood?" The scenario was that some patients improved with blood, while others died. It was in 1901 that we learned there are actually four primary types of blood and that they are certainly not all compatible in humans.


Now the leadership of case management is asking a timely (and correct) question: "What if we drew a line in the sand and made it a case management standard that minimum requirements should be adhered to in order to be considered a case manager?"


"What could happen?"


Not everyone could hang out a "case manager" shingle.


Reimbursement can become a reality.


Although healthcare legislation is a moving target at this writing, there is enough information out there for us to realize that the time is NOW!! We can no longer stand on both sides of the fence. There are several initiatives now on the Web site of the House Ways and Means Committee that is addressing the abysmal unnecessary readmissions rates, how they can be decreased, how quality can be improved, and how reimbursement can be the "stick" (sorry, I didn't see many "carrots"). The House Bill, HR 3200, section 1151, "Reducing Potentially Preventable Rehospitalizations," declares that financial penalties will be imposed on hospitals with high rates in three conditions. These conditions will be identified from high volume or cost and associated with National Quality Forum (NQF) measures. It can be extrapolated from Centers for Medicare & Medicaid Services (CMS) studies that congestive heart failure, acute myocardial infarction, and pneumonia may be three easy targets.


Several of the initiatives in these bills refer to transitions of care and propose "transitional care clinicians" who may or may not be from the licensed, healthcare working professions. It alludes to that these clinicians must meet criteria, but these criteria are not defined. Case Management Society of America (CMSA) believes that we cannot leave this to interpretation. We must clearly define minimum qualifications of a case manager and then encourage all who are working to define healthcare reform initiatives to include those qualification statements within the bill or statutory regulation.


Some of the services and interventions being identified include the following:


Providing care coordination services to assist in transitions from the targeted hospital to other settings.


Ensuring that individuals receive a summary of care and medication orders upon discharge.


Developing a quality-improvement plan to assess and remedy preventable readmission rates.



The bill identifies patient-centered and population-based measures and includes the assessment of


* outcomes and functional status of patients;


* the continuity and coordination of care and care transitions for patients across providers and healthcare settings, including end of life care;


* patient experience and patient engagement;


* the safety, effectiveness, and timeliness of care;


* health disparities including those associated with individual race, ethnicity, age, gender, and place of residence or language; and


* the efficiency and resource use in the provision of care.



In the Senate Health, Education Labor and Pensions Committee, Affordable Health Choices Act, there is a recommendation that would require health insurers to provide financial incentives to providers to better coordinate care through case management and chronic disease management, promote wellness and health-improvement activities, improve patient safety, and reduce medical errors (Kaiser Family Foundation, 2009).


Would we not, as case managers, say the description of services and quality measures highlight many of the interventions of case management? Then, the question still remains: "Who would be a qualified professional to address these interventions?" Case managers naturally!! But neither the professional association nor professional leadership have truly identified the training or skill sets required to be a case manager. As we move into the healthcare reform agenda, it is now time to take a firm stance and ensure that case managers are identified as professional providers of care. CMSA further supports this initiative through its Standards of Practice and its newly developed Case Management Model Act of 2009. The Case Management Model Act of 2009 addresses many of the key building blocks to ensure a successful healthcare program, including a case manager's qualifications. Both the CMSA Standards of Practice and the Case Management Model Act of 2009 provide the following qualification standard:


Case managers shall maintain competence in their area(s) of practice by having one of the following:


1. 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; and/or


2. Baccalaureate or graduate degree in social work, nursing, or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of the persons being served. The degree must be from an institution that is fully accredited by a nationally recognized educational accreditation organization, and the individual must have completed a supervised field experience in case management, health, or behavioral health as part of the degree requirements.



Case management offers a unique and effective way to mobilize resources to promote quality-based and cost-effective outcomes for a wide range of populations with different healthcare needs. Case managers provide the services identified in various healthcare bills and initiatives. In building consensus of an accepted standard supporting the qualifications of a case manager, we can lead the way to establish case management as one of the most effective solutions in healthcare and a fundamental pillar of healthcare reform.




Kaiser Family Foundation. (October 1, 2009). Side-by-side comparison of major health care reform proposals. Retrieved from[Context Link]


Kihlstrom, J. (2009). Hand washing by health care providers. Retrieved August 10, 2009, from[Context Link]