CMSA Today - Issue 2, 2015 - (Page 14)

Standards and Regulatory Requirements Divergent Expectations Emerging Quality Standards and Regulatory Requirements for Case Management Organizations BY GARRY CARNEAL, JD, MA C ase management has evolved over time to meet the divergent expectations of multiple stakeholders in the U.S. health care system. The significance of case management is increasing as the health care system becomes further integrated through population health management initiatives, as well as increasingly specialized as the practice of medicine becomes more dynamic and complex. Case management connects patients who have complex health and social needs to providers that track their care over the continuum. As a result, the quality of those services is an important issue on clinical, policy, and business levels. As highlighted by the quality theme in this issue, case managers have been very proactive in drafting and implementing individual certification programs to help define and promote best practices in the field, among other initiatives. Yet, one area that was and has been neglected is the oversight of the health plans, systems, and other organizations that sponsor and/or provide case management or population health services. For example, few if any states have adopted enabling regulations that license organizations to provide case management services in a fashion similar to health plans or utilization management organizations. StAndARdS oF PRACtiCE After its publication in 1995, CMSA's Standards of Practice for Case Management was a good starting point for the adoption of national standards providing guidance to both individual case managers, provider systems, health plans, and other stakeholders. This publication sets out core principles and provides voluntary practice guidelines. Despite having been introduced two decades ago, the standards are regularly updated and were last revised in 2010. According to CMSA, "The Standards of Practice are intended to identify and address important foundational knowledge and skills of the case manager within a spectrum of case management practice settings and specialties." CMSA notes that the 2010 standards reflect 14 CMSA TODAY Issue 2 * 2015 many changes in the industry that resonate with current practices today, including the need to: * Reduce fragmentation in the health care system by identifying quality-based pathways to care * Use evidence-based guidelines to promote standardized benchmarks * Easily navigate transitions of care by promoting the continuum of care * Promote patient engagement strategies and other standardized practice tools * Expand interdisciplinary provider teams to promote better outcomes Simply put, the Standards of Practice have become a source for several certification and accreditation standards, along with the Case Management Model Act as highlighted below. ACCREditAtion StAndARdS With the evolution of the medical management system during the 1990s, many health plans and provider systems began to move away from their sole reliance on utilization management interventions and began to more actively implement case management services. As a result, public policy makers and health care experts began to emphasize the need to develop quality standards for managed care organizations to offer case management services. In addition to a number of certification programs geared at credentialing individual case managers, a number of accreditation programs have been launched in recent years for organizations sponsoring case management services. In 1999, URAC launched the first standalone accreditation program that assesses the operations of case management services within various types of health care organizations. URAC's Case Management Accreditation Standards provide a voluntary framework that defines the scope of practice for case management organizations. The standards build on ethical and professional obligations of case managers to create a parallel obligation on organizations providing case management services. If past practices are a guide for the future, case management accreditation may become the community standard by which organizations offering case management are evaluated. In 2012, NCQA also launched a case management accreditation program. This set of guidelines is comprehensive, evidence-based, and dedicated to quality improvement, and can also be used for case management programs in provider, payer, or community-based organizations. The framework of the NCQA program addresses how case management services are delivered and focuses on care coordination and quality of care. It is designed for health plans, providers, population health management organizations, community-based care management organizations, and everything in between. The Joint Commission, CARF International, and several other nonprofit agencies offer specific quality standards or entire accreditation programs geared to case management. REgulAtionS Despite the need for this kind of oversight, most states have not adopted a regulatory

Table of Contents for the Digital Edition of CMSA Today - Issue 2, 2015

President’s Letter
Association News
Cmsa Corporate Partners
Index of Advertisers
Divergent Expectations
Realizing the Broad-Reaching Benefits of Board Certification
Certification by the Numbers

CMSA Today - Issue 2, 2015