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CONSULTING MANAGEMENT INNOVATORS August 15, 2013

FOCUS GROUPS

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Executive Summary For many years, CMSA held the position of being the primary professional organization for case managers. Today, a quick glance at the marketplace reveals a much different picture. The good news, however, there is still a lot of blue ocean space available to CMSA. As healthcare continues to evolve, additional players will enter the market forcing existing players to continually evolve their products and services, become irrelevant, or even go out of business. Results of recent focus groups demonstrated CMSA retains the enviable position as the trusted source for case managers. The following report outlines key opportunities upon which CMSA can rapidly move forward and establish a position of relevance and value as “the professional society for the practice of case management.”

The role of a professional society is to: • •

To advocate for the profession To defend access to practice

Take a look at the CMSA Strategy mind map to see where CMSA resources are currently being deployed and compare that picture to the revised strategy map which has been reimagined to fit with the CMSA outlined by the focus groups.

Goals for this section of the retreat agenda: 1. Reach consensus that CMSA’s primary role going forward is to create a sustainable case management workforce. The chaos and lack of definition in the industry will ultimately lead to the demise of case management as it is defined today. Powerful entities, both business and government, combined with healthcare reform are rapidly reshaping the practice of case management. CMSA still has a very small window of opportunity in which the professional society can provide the level of leadership necessary to sustain the practice. 2. Empower the staff to develop strategies (based on the combined research findings) that will fast-track the association to a sustainable future. These recommendations will be based on the previously approved engagement acceleration plan which incorporates resources from the free to fee business model. 3. Acknowledge that the resources CMSA is being asked to provide do not currently exist (in most cases). Development of these resources will require courage, teamwork and the full cooperation and expertise of every board member. The timelines from design to implementation will be outrageously fast and may not be complete at launch. 2


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Across all practice settings and years of experience in case management, “a lack of understanding and standardization of the role of case managers” was at the core of and central to most other issues.

STAFFING and WORKLOAD Throughout the focus groups, I worked to tease apart the issues around staffing and workforce. In general, across all practice settings and all levels of experience this issue came across as: 1. 2. 3. 4. 5. 6. 7.

Not enough staff, or insufficient staff Lack of qualified staff Not enough people applying with the right qualifications Enough people with clinical skills, but not enough with critical thinking skills HR departments that don’t know how to hire for case management positions Not enough people applying whether qualified or not The correct patient to CM ratio

Staffing frequently becomes an issue when non-case management duties are delegated to the case management department. This seemed to be most prevalent in acute care. For example, many case managers are heavily involved in the accreditation process, while maintaining a full caseload. Although they understand the importance of participating in the process to ensure understanding of the standards related to accreditation, it I have trouble filling spots, because I represents a burdensome addition to an already full workload, and could can’t find qualified applicants…so, it “We adopted the CMSA standards compromise quality case management performance and/or patient comes to not having enough staff, and worked with our community but not because I don’t have enough satisfaction. Participants frequently identified delegation of a variety of college system within the state to applicants. I have the FTEs, but end administrative tasks to the case management department in addition to develop a case management up interviewing and interviewing. their patient caseload. Work comp was the only area that did not seem to assistant program. In acute Some people really don’t wantcare to settings you pair a nurse’s aide with be struggling with this issue…Citing, however, the WC caseload does ebb and work this hard the RN. If you have the title of case flow, and is more likely to be unpredictable. As we discussed this issue, I explored the degree to which participants used the CMSA Standards of Practice. Participants unanimously felt that the SOP was a great tool and guideline for them individually. However, in its current form, the SOP is of no real value in working with their employers. Participants want their employers to understand the SOP and want to use it to explain to their employer what case managers should and should not be

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manager then you’re licensed either as a social worker, or as a registered nurse. And if you’re not a case manager you are a case manager assistant. It’s the same rule of delegation we had in the hospital. I knew what a nurse’s aide could do for me, as a nurse. There is a lot that they can take off which allows us to be more competitive in our staffing.”


doing. They also cited similar issues with HR departments and nurse recruiters who did not know how to screen applicants for case management positions. Recommendation: One-page version of the SOP with bullet points for use with employers and HR departments. Not surprisingly, the topic of workload typically meant too large a caseload. Both managed care and acute care case managers were quick to point out the acuity models that are available for some hospital nurses. While they recognize the complexity of establishing something like the caseload calculator, a simple benchmarking study would likely be well received by the community. On the other hand, workload issues also include delegating tasks to nurses (specifically) that nurses don’t need to be doing. These “tasks” largely fall into two categories, administrative and direct patient care. They also largely blame themselves for not being good self-advocates, stating that nurses will take on a larger workload than most any other professional. Finally, the issue we all deal with relative to workload…the notion that we keep adding things to our plates, but nothing ever seems to go away. Constant change came through on the initial survey as an issue of concern for case managers. As we unpacked that a little further in the focus groups, I was a bit surprised, however, to discover that participants tied this concern back to the staffing/hiring process. For example, how does one effectively screen applicants for the ability to thrive in the midst of constant change? Although no less complex, the constant changes in reimbursement (Medicare/Medicaid) was at least slightly more quantifiable as a deliverable to the community. Falling in line with the concept of curating content, the community expects CMSA to filter the enormous amounts of information (relative to reimbursement) and alert them to issues of significance. Furthermore, they would like to see CMSA make policy statements, and/or recommendations should policy be too strong a step.

Staffing and workload quickly morph into a new and more complex dynamic, that being, administrators don’t know what case managers are supposed to be doing, nor do they understand the value the CM brings to the organization and to the patient. Therefore, how can they be effective and efficient in managing workload and staffing issues? Without exception, participants believe the role of case management is currently too broadly defined. In CMSA’s desire to embrace the full community of professionals, it risks delivering products and services that have become too watered down to deliver significant value.

We are responsible for bringing this information to our staff and ultimately to the rest of our facilities. And if we don’t have that information…it can’t be us going out there and searching the web 24/7. There’s got to be some way of getting the information to us so that we’re prepared and CMS doesn’t come and take us by surprise one day.

Models of CM Particularly in hospitals and managed care, participants indicated their employers constantly changed the model of case management being implemented. As the model changes, it also affects workload because many of the “changing” 5


roles are not well defined. Acute care participants, in particular, indicated knowing the acuity of their patient population and consistently knowing what each member of the team is supposed to do is a critical issue. Particularly in acute care, there was consistent need for case studies and examples of ways in which case management programs are being successfully implemented. The case management community would find value in CMSA providing examples of “best in class” programs. Interesting aside…there were a few examples of individuals who worked in systems where the payer case manager worked in collaboration with the hospital transition coordinator (having abandoned the role of UR for TOC). Legislation and Regulatory changes Participants indicated keeping up with regulatory changes, particularly those related to reimbursement (CMS), have become almost impossible to manage. Participants cited a variety of interpretive guidelines (available through other organizations, i.e., Kaiser) as being an important tool. In fact, most participants indicated they believed it was a primary role of their professional society to filter, analyze and interpret that which is important to or impacts their practice. In fact, most believed CMSA should be offering recommendations and/or interpretations of regulations, policies, legislation, etc. Provision of this benefit could come in the form of a blog, a discussion forum, as well as FAQ type documents. Some groups took this concern a little further to include the need for similar FAQ updates on system changes (i.e., InterQual, Milliman). Apparently these systems implement frequent changes that affect reimbursement. From the perspective of the case manager, keeping up with these changes is intensely time consuming and also requires collaboration with the payer, medical director, etc. While it is not reasonable that CMSA could “develop” such a resource, it might be worth investigating what a vicious of they going to the “AIt’slist serve iscycle what resources are already available through partnership arrangements. ER because resources that we called them the in the old days direct them to are either backed now it’s blogging, I guess. Throughout the focus groups, I became keenly aware of need to bridge the up, something unavailable,that don’tsays exist, or But, “hey gap between case managers working in the acute setting and those in even in their medical homes, if these new guidelines came external practice settings. The acute care case managers (at least those in they have a condition that out; this is how we are the focus groups) were valiantly trying to conduct case management per warrants an appointment they interpreting thisweeks is may not get them one forand three the CMSA Standards of Practice. However, there seems to be massive what we think it means for maybe four weeks. We’re of Or, improper utilization confusion as to the appropriate role. CMSA may wish to consider if this you and your organization.” finding out aLike lot of theperson primary resources. the represents an unarticulated need and/or falls into the category of “access care offices aren’t even that’s got three free actually to practice” function. In particular, how could CMSA help to quantify and staffing with people who answer wheelchairs because every qualify the actual role of the acute care case manager? the phone anymore they are time they come to the hospital recording messages. So we are somebody didn’t look at their Inadequate resources directing these people to do the record to see whattrying had to been right thing, they’re do provided before.” the right thing, but when they 6 get out there to their medical home in the communities, it’s not there.


Inadequate resources includes Community, state, federal, pharmaceutical assistance, specialty physicians (that will accept specific types of reimbursement) All focus groups (regardless of practice setting or years of experience) were in agreement that “community” resources are rapidly drying up. The question of inadequate resources (related to resource allocation) was a topic of more debate. The focus groups were interested in CMSA providing updates when Federal dollars become available for various projects. Many participants indicated they would be interested and willing to seek grant funding if they were aware of the opportunities. Most indicated they simply don’t have time on the job and don’t take personal time to conduct the research. In particular, they referenced a session at the CMSA 2012 conference which educated attendees about waiver and grant programs. The speaker provided a website and links. Is this something that CMI’s grant division could provide as a service for CMSA? “If you look at case management and levels of certification, regardless of practice setting…you take this While there is much overlap with content from earlier sections, a few new test and you get this elements emerged of significance. Participants indicated this issue is not certificate the CCM. What just a lack of understanding of the role of the case manager, but a lack of does it mean to your career understanding of all the disciplines that can bring skills to the table. Of path? It might mean significance here is the notion of a “skills” based model vs. educational something to you but what background/discipline. While the Standards of Practice do address the does it really mean? After you “qualifications” for practicing case managers, possibly a more practical tool (i.e., a Skills Map) would assist case managers in communicating with take the test and have that piece of paper, credentialing is their employers. See appendix 1 – IEMA Skills Map as an example. very passive; it doesn’t mean anything to others. Although Furthermore, there was much discussion about the various roles case we may have worked hard managers play, particularly when they work in, or are involved with acute and put a lot into trying to care CM. There was much discussion about CM evolving towards focus on what we can do to “specialization in case management” simply because of the increasing make the system better for number of roles being categorized under the care management umbrella. the people we advocate for, a certification doesn’t define our The Community clearly wants CMSA to help more clearly identify the role career ladder and doesn’t give for case managers and provide physician education programs (CME) delivered at ACHE, AMA, etc. This concept also extended to include lack of you any more money, it doesn’t put you in a different provider engagement, which ultimately reflects the lack of understanding role, is just like they used to of the role of the case manager. say “a nurse is a nurse, is a nurse, is a nurse.” And we all This represents an opportunity for CMSA to compete less with (CCMC, Dorland, etc.) in the education marketplace. Rather serving as the clearing know that’s not true….because there are house for all case management education? different levels, but our career path is not clear.” 7 Lack of support. Lack of understanding. Devaluation of the role of case manager.


Taken a step further, as we develop a reasonably robust marketplace of material, CMSA could begin to compile information about those resources (a kind of digital reference librarian). It’s an element of content curation. CMSA doesn’t need to create everything. There is a lot of talent in the community that would like to be embraced. Give them a place. The role of CMSA is to advocate for the profession and protect access to practice.

Amazon marketplace Explore something like the Amazon.com affiliate program and turn those who are currently competing with CMSA into resources for CMSA. https://affiliate-program.amazon.com/

Lack of Defined Career Ladder All groups identified the lack of a professional career ladder for case managers as an area of interest and something of value CMSA could and should be providing the industry. The discussion centered around practical ways in which case managers can move forward as well as laterally, and/or into specialty areas. The discussion did not particularly center around level of education, nor on certification. In fact, most participants indicated additional education and/or certification had not assisted in career advancement. Many participants cited other professions who have a clearly defined process by which they can progress through their career. Most participants felt the only advancement option (in terms of salary advancement) involved moving out of their clinical CM role and into the management team. For many, moving into management was not deemed career advancement, yet was necessary in order to receive salary increases. of however, helping case path tool include a outlines various How

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I have people who work UR and they deal with the case managers on the payer side. In my care transitions, I have social workers and a nurse practitioner that are going to run the psych program. So you have all of these different folks that are now in what’s called the care management department. My bed managers are in my care management department. So, you know, they’re all doing different roles and it’s almost like case management is becoming a specialization.”

Regarding the CMSA standards practice, from a clinical perspective it is a useful tool, it’s useless as a business tool in employers understand what managers actually. A career that CMSA could explore might version of the SOP that the roles and functions at levels for case managers. could CMSA work more effectively with the various

If a claims adjuster gets an advance and gets certified and gets that, they get monetary rewards for that. When we do CCM, we don’t. So, I guess it’s kind of – whether it’s advanced practice or whether it’s helping employers or – I don’t know how you could do it but I think is kind of what we are talking about right? I did my MBA as well. All it did was acquire more debt


certifying bodies to lobby employers on the behalf of CMs? Or, could CMSA accredit case management certifications? The biggest concern around clarification of these roles is the amount of undefined “stuff” that seems to get offloaded onto the case management department because hospital employers (in particular) don’t seem to know to where it should be delegated. The following is a great example of the kind of public policy activity the case management community believes CMSA should be engaged in: Respondent quote: I think that we should get legislative alerts – I’m the chairman of the school board where I live and I get legislative alerts from the SBA, from my association, when the state legislature is in session I am constantly getting updates saying, “this is what’s going on that’s going to affect in education.” “This is the bill; this is a summary of the bill”. And they have policy experts and lobbyist who keep us as members informed. And a lot of what we’re talking about is a direct result of what’s going on or not going on in Washington. And for me, I don’t have time to read every bill that’s been put forward to HHS, I think that many of the things that we’re talking about are a direct result of legislation and having an association that keeps me up to date on not only what is coming, but what is their position on it. It’s not necessarily going to be my position but I do appreciate knowing what position my member organization is taking and then I can make a decision whether I want to lobby on the national level with my folks. The community is also looking for CMSA to comment on or establish positions on a variety of key topics, specifically reimbursement issues like readmissions. See below for an example of this type of comment/request. No one does anything just because. Everyone has – “I don’t know what CMSA’s position is on “all cause readmissions”, but I there’s a value on everything think that we should be thinking about what the effect of all cause readmissions would be. If you have a patient that leaves the hospital for one that everyone does. Whether its emotional value whether reason and comes back for an entirely different reason, they go over to all it’s monetary value or cause readmissions and if they get readmitted because they are in a car whatever it is, there’s a value. accident and it’s completely unrelated to the reasons that they were If the career path is not admitted for, it’s just ridiculous what kind of position that it puts the acute defined for us but we continue care hospital in to – for readmissions.” to try and educate ourselves to be the best, to know the Outcomes best, to help other people, there is a point in it, without The community is clearly looking to CMSA to help them find ways to being narcissistic when people measure outcomes. The following is a quote from one participant who say “what is in it for me.” expressed this particularly well: Because everyone needs “I was in a presentation this week where the speaker said “our length of stay something, and the profession needs a career ladder. went up, but we know that it was because we had more observation, less short stay, in-patient. When that happens then you have a longer length of 9


stay.” And so I asked the question, “how did you know that?” “How did you prove that was why your length of stay went up and just not because people are staying longer?” Those tools, ways to measure outcomes, would be helpful.” The community is also interested in a CMSA “seal of approval” for a variety of resources. Case managers work 24/7, but many of the resources they need are only available 8-5, Monday-Friday. They are asking for a way to have some confidence that the resources they are recommending meet a level of quality as defined by CMSA. With regard to access to consistent information and technology…while no one expected CMSA to provide an EMR, or even support a single technology…the groups expressed what seems to represent an unarticulated need for CMSA to assist case managers in figuring out how to bridge the communications gap, in accessing the right information at the right time and finding the right resources at the right time. This skill set is incumbent with the role of the case manager. Unfortunately, the dramatically increasing complexity of the healthcare system is impacting the overall efficiency of case managers. They don’t know how to fix the problem, but recognize it is contributing to the “lack of understanding’ of the role of the case manager

PROVIDER ENGAGEMENT This topic emerged primarily as lack of physician engagement. Participants largely feel that case managers (nurses, nurse practitioners, etc.) are frequently not allowed to practice at their full scope of practice. The community is looking to their professional association to:

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Identify the core and role responsibilities of case manager and the roles and responsibilities for those who function in extended roles

If we can identify roles for those in extender positions, possibly we can move towards decreasing the patient to CM ratio

If the SOP can support these roles as defined by the professional society, it can serve as a foundational tool upon which organizations can build best practice case management processes and procedures

They believe wholeheartedly in the Standards of Practice, but do not believe they go far enough.

The community believes CMSA should be able to provide more of a skills map that connects the skills and capabilities according to levels of education, licensure, etc.

We created a little video vignette of what a case manager is and it looped on our hospital channel so it was on all the patients TV’s. My administrators are really excited about case management…we are going to start outpatient case management. They read these studies that say case management has saved so much money and then they redefine our role and say why aren’t you guys saving money? These studies say you’re supposed to be saving us money. And we’ve been trying to convince them to let us be case managers and we can do that. So we’ve got the lack of support, the misunderstanding, and it’s very frustrating because they really want it to happen, they just don’t know how to make it happen because they don’t understand.


The community also wants to see CMSA active at the employer level and in communication with CEOs, CFO, etc. and provide similar education to this group of individuals that they described for physicians. The education for corporate leaders would be focused more around how to establish mentor programs, or the core principles of successful case management programs. Clearly there is an unarticulated need here for people to provide training in setting up CM programs and consulting around effective strategies. We know a number of people in the CMSA community who do this kind of consulting work. Not sure how CMSA could better capitalize on this issue, but it is certainly one to be considered. The community also recognizes that effective case management is a fine balance between patient advocacy and running a business that can stay in business. This potentially indicates an unarticulated need for educational programs around the “business” of case management.

Public Relations and branding The community believes CM Week is a great start at acknowledging the role case managers play in the effective delivery of healthcare, but they believe it is woefully insufficient. They believe nursing and social work do a much better job of educating the professional community about their respective roles. The community is looking to CMSA to provide them the tools and resources they need to explain what they do and why it’s important. They want slick, quick and to the point ways of making impact statements, elevator pitches. In public policy, they want short and to the point issue briefs. Specifically in the area of healthcare reform, the community wants to know what’s coming. There seems to be LOTS of interpretations of “what to expect” and the community is looking to CMSA to be the trusted source of information. They would like to see a blog from Cheri and/or the board as well as regular FAQ type documents, and webinars (when appropriate). The community is unclear about how to best get state level information…again, an unarticulated need for access to information that CMSA may need to consider. The community also seemed to express an unarticulated need for some type of glossary of terms and explanations as to their significance in case/care management. This opportunity came out of discussions regarding that rate of change and unrelenting changes in healthcare system, corporate, models of CM, legislative, regulatory, types of cases, clinical issues, technology…etc.

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OTHER OBSERVATIONS CMSA chapters used to have a very active vendor community that helped to support chapter operations, contribute programs and financial resources. With changes in pharma and device regulations, much of that support has dried up. The vendor community provided diversity in perspective and strength in many instances. While no recommendations came out of this discussion, it is a potentially important background statistic. Note, only minor awareness of and use of NTOCC tools and resources, which is a big opportunity for CMSA to partner with NTOCC and extend into the case management community

EDUCATIONAL RECOMMENDATIONS Interestingly, a larger than expected numbers of participants are continuing to explore advanced education (not just certification). The community expressed a desire for CMSA to provide access to more “journal” content, even if it is not an official publication of CMSA. From a practical perspective, obviously CMSA cannot be the only publisher of content for the case management industry. However, this does point to the notion that the community does view CMSA as a trusted source and will find value in resources that are deemed appropriate (as vetted by CMSA). This included behavioral health and any literature pertinent to the community. This idea is in keeping with the content curation concept previously recommended An interesting observation, particularly from the social workers in the focus groups, but inclusive of nurses as well, the notion that CMSA has become too broad in its focus…thereby, in its effort to become the umbrella organization for all case managers, the value of its offerings have become too diluted and of little value. Educational offerings should be more focused with more specialized and clear message to market. For example, case management programming for social workers, programming specific to CMs in work comp, etc.

SAMPLE SKILLS MAP SKILLS MAP PLANNING TOOL 12


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Focus group report