Case Management

Case Management standard 7, dealing with Case Management Knowledge Domains, gets a good housecleaning in the v. 3.1 revision.  The only substantive change is the elimination of a requirement that case managers be trained in URAC's current Case Management standards.  Since Core 7 requires URAC training on the applicable standards in any event, this was an unnecessary clause.  The rest of it is simply the breaking up into 4 separate subsections what was once a single subsection, allowing the reviewer more precise scoring.

The v. 3.0 version read:

The organization requires case managers to be educated in current principles, procedures, and knowledge domains of case management based on nationally recognized standards of case management. Such education includes: (Prim)
(a) The organization’s case management process, policies and procedures; state-specific requirements; professional roles and resources; and requirements specific to the clinical or payer populations being served; (Primary)
(b) URAC’s current Case Management Standards; and (Secondary)
(c) Relevant professional education on at least an annual basis. (Secondary)

The v. 3.1 version now reads:

The organization requires case managers to be educated in current principles, procedures, and knowledge domains of case management based on nationally recognized standards of case management. Such education includes: (Primary)
(a) The organization’s case management process, policies and procedures; (Primary)
(b) Applicable regulatory requirements; (Prim)
(c) Professional roles and resources; (Primary)
(d) Requirements specific to the clinical or payer populations being served; and (Primary)
(e) Relevant professional education on at least an annual basis. (Secondary)

CM 2 provides:

The organization:
(a) Establishes guidelines for reasonable case manager caseload with supporting rationale based on factors such as severity of cases, complexity of cases, role requirements of case managers, and other relevant factors; and
(b) Applies a process to monitor caseload based on guidelines developed by the organization; and
(c) Consistent with the guidelines established in CM 2 (a), employs/contracts with an adequate number of case management personnel to provide services to the consumers of the program.

The standard is weighted “4”, and all subsections are considered to be primary elements.

On the one hand, the standard does not appear to be particularly onerous, as URAC is quite explicit in not specifying what an appropriate caseload is for a case management organization.  However, this is a bit deceptive, as the standard does have a certain degree of rigor embedded in it.

At the outset, the organization must define “caseload”, and be consistent in its application of that definition throughout its policies and procedures.  In our experience as consultants, many first-time applicants for accreditation do not meet this basic requirement at the outset of their accreditation process.

Second, the organization must develop caseload criteria which must reflect mindfulness about cases severity, complexity, and what role the case managers will play.  URAC reveals its deep respect for and association with the Case Management Society of America (“CMSA”) by referring applicants to that organization’s website (www.cmsa.org) for assistance in developing such criteria.

Third, the organization must have a mechanism for monitoring caseload with reference to these criteria.  Most organizations with which we have dealt as consultants use electronic case management tracking systems for this purpose.  Absent such software, simple spreadsheet analysis will suffice.  However, this tracking should be an ongoing activity of the case management supervisor, as the expectation of this standard is that the organization be prepared to adjust its staffing to accommodate any changes in caseload.

Fourth, the client/consumer complaint log should be sufficiently sophisticated to pick up any trends that might indicate that the caseload is getting too high.  Indicators in this category might include complaints about slow responsiveness from case managers, poor coordination, or even rude treatment by case managers.

The Program Guide suggests that an organization submit the following for purposes of the desktop review:

• Policy and procedure for determining case manager case load/staffing pattern.
• Consumer/client complaint log.
• Number of case managers/number of cases managed over the last year.

However, we recommend to our clients that they also submit any analyses or reports of caseload that they can submit.

The on-site review, the Program Guide tells us, will focus on:

• Interview with case management organization administrator(s) and supervisors.
• Interviews with randomly selected case managers.
• Review of consumer/client complaint log.
• Interview with appropriate quality management personnel.
• Caseload monitoring tool

What is interesting to note about this list of activities is the interview with appropriate quality management personnel.  This speaks to URAC’s commitment to interdepartmental coordination and integration of quality management throughout the program.  It also suggests that case manager caseload might be the subject of a Quality Improvement Project (see Core 35-37).

CM 1 provides:

The case management program’s description and/or written policies and procedures include a definition of case management consistent with these Standards.

The standard is weighted “4”, and the entire standard is a primary element.

The applicant has some flexibility about what documentation to submit for desktop review. The Program Guide suggests that the reviewer will accept either a policy and procedure or some other document that constitutes a program description. In addition, organization charts and descriptions of case management staff members and their positions should be submitted.

However, we have noted that, at least among some URAC reviewers this year, a tendency to construe quite strictly in the last four sentences of this standard, “consistent with these Standards.” While the Program Guide makes it clear that the “definition of case management does not have to be the same as the definition in URAC’s Case Management Standards,” interpretations by reviewers in some recent reviews suggest that your definition better be pretty close to URAC’s:

A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet a consumer’s health needs through communication and available resources to promote quality cost-effective outcomes.

This should not be surprising, given this language, also found in the Program Guide:

It is extremely important that the applicant’s definition of case management is consistent with URAC’s definition of case management. If you do not have a member centric, collaborative approach model you will struggle to meet the intent of the case management standards.

There is another hint within the Program Guide about the particular language URAC finds important:

If the organization also uses a case manager for making benefits determinations the advocacy role is clearly defined.

The emphasis on “advocacy” is in the Program Guide, and should be considered part of the “tea leaves” used to predict have a reviewer at will apply this standard to your organization’s case management program.

Once you get past the desktop review, however, the on-site review should pose few problems, unless, that is, you have a member or members of your staff not on board with the collaborative approach required by the standards. This is pretty rare in our experience, but is certainly something to emphasize in staff training.