Source: CMSA Today
BY GARRY CARNEAL, JD, MA, AND MELANIE PRINCE, EdD, MSN, BSN, RN, NE-BC, CCM, FCM, FAAN
During the rise of payer-sponsored case management programs in the 1990s, the Case Management Society of America (CMSA) and URAC (Utilization Review Accreditation Commission) began working together to help standardize key workflows associated with case management programs. Part of this collaboration was driven by several large health plans who were moving away from pre-authorization requirements and promoting complex condition management. Although health plans returned to more traditional utilization management (UM) practices over time, payer-based case management programs have remained an important aspect of population health initiatives, especially for patients with one or more co-morbidities.
This article highlights some of the contributions that URAC’s Case Management Accreditation Program has made to promoting quality-based care since its launch in June of 1999 including the long-standing collaborative efforts of URAC and CMSA in developing standards for organizational and individual case management practice.
The Need for Case Management Accreditation
In the 1990s, case management was expanding rapidly in both provider and payer settings. A primary concern at the time focused on the variability of staffing models and workflows within these programs. Some consumer advocates also expressed concern about the quality of the services being provided.
As a result, the hope was to develop case management standards for organizations to promote standardization and best practices through URAC’s accreditation framework. A URAC January 1998 press release announced the development of the standards:
“It has always been our goal to keep pace with changes in the managed care industry…Since we began accrediting utilization review programs in 1991, much of the industry has integrated a flexible case management approach into their managed care programs. The development of case management standards will ensure that our accreditation programs continue to keep pace with the best practices of the managed care industry.”
Garry Carneal, JA, MA, former president and CEO at URAC (1996-2005), teamed up with Jeanne Boling, RN, MSN, CRRN, CDMS, CCM, former executive director at CMSA (1994-2006), to lead the initiative. With active participation from the CMSA community and URAC Case Management Standards Committee, the accreditation agency formally adopted the Case Management Organization Standards in June 1999. Five months later, URAC announced it had accredited the first wave of case management organizations.
The importance of URAC and CMSA’s efforts to standardize case management programs was further highlighted in the 2002 joint publication, which identified and analyzed over 7,000 case management state and federal regulatory provisions. The 516-page book, entitled Case Management Trends: An Overview of Recent Industry & Regulatory Developments, detailed many of the political, business and social forces that directly affected the medical management system and practice of case management. Among other findings, the book featured many of the different aspects of government-sponsored case management programs that supported different targeted populations.
Fast forward to 2024, URAC leadership was asked to reflect on the rationale, driving factors and strategic need that led to the development of the case management accreditation program in its current form. They shared the following:
“URAC first developed our CM accreditation program as a complement to utilization review, recognizing that some patients required additional assistance and are referred to case management. The case management program recognizes the complexity of patient care and provides a framework for ensuring patients have access to improved care and quality of life. Over the years, as we have revised the program, our goal has been to provide a quality framework for organizations while continuously improving our standards and program to meet the needs of the industry. Our latest revision recognizes the movement towards health equity, continuously updating regulations, and the challenges associated with coordinated care. Our programs recognize the importance of certification for case managers and ensure the appropriate credentials are held for the state the individual is working in. In addition, there was a strong case for recognizing medical case management and workers’ compensation case management as distinct functions, and we developed our program to allow organizations to gain recognition for the function(s) they perform.”
Source: URAC 2024.
The URAC Standards
The URAC Standards represent the successful integration of 7,000 statutes and regulations into a streamlined set of principles. The following areas were initially covered under version 1.0:
- Organizational requirements
- Staff structure and qualifications
- The case management process
- Quality improvement
- Information management
- Oversight of delegated functions
- Ethics
- Complaint mechanism
Today, URAC is on version 7.0 of their standards. Two modules are offered which cover both health and workers’ compensation case management programs. The current standards are organized into the following sections:
- Risk management
- Operations and infrastructure
- Performance monitoring and improvement
- Consumer protection and empowerment
- CM staff qualifications, training and responsibilities
- Measures reporting
- Module: Medical Case Management Program
- Module: Workers’ Compensation Case Management
URAC’s Case Management Accreditation Program strives to promote quality, efficiency and safety across continuums and transitions of care. When URAC considers how to structure an accreditation program, the agency aims to closely align the standards with how the industry visualizes itself but also solicits feedback from a broad range of stakeholders. The ultimate focus is always the patient.
Related Case Management Standards of Practice
Over the years, other organizational-related standards and model acts have been developed to promote quality-based accreditation programs. This includes CMSA’s Standards of Practice for Case Management, which was originally adopted in 1995 (CMSA, 2022), and the Case Management Model Act, which was originally adopted in 2009 (CMSA, 2018).
Recently, a task force was charged with updating the Standards of Practice to reflect the execution of clinical practice that is flexible, dynamic and inclusive. The task force drew upon the lessons learned from a healthcare system thrust into crisis management from the COVID-19 pandemic. The 2022 updated CMSA Standards provide guidance to better support the case manager’s practice to serve all populations in ways that may require system-wide adaptation, creative strategies and innovation without compromising quality. In addition, Dr. Melanie Prince is currently working with a team of experts to ensure the CMSA Standards of Practice are supplemented with health equity principles and organizational standards that ensure quality care for diverse populations, promoting equity, inclusion and belonging in both patient care and workforce development.
CMSA’s Public Policy Committee took the lead in drafting the Case Management Model Act in 2009, which promoted model legislation at the federal and state levels. The preamble reads in part:
“The Case Management (CM) Model Act establishes the key elements of a comprehensive Case Management Program that should be implemented at both the federal and state levels. The Case Management Society of America (CMSA) encourages public policymakers to review and use the provisions of this CM Model Act for legislative and regulatory initiatives geared to reducing health care costs, improving the coordination and transitions of care, enhancing quality, and promoting better clinical outcomes.”
The CM Model Act was last updated in 2017.
Aligning with the CMSA Standards of Practice
The following table depicts how the URAC Case Management Accreditation Program aligns with CMSA’s Standards of Practice:
CMSA Standards of Practice for Case Managers | URAC Quality Standards for Healthcare Organizations | Alignment |
Ensures High-Quality Care: Provides a framework for consistent, evidence-based and client-centered care that enhances client outcomes and satisfaction. | Demonstrates Commitment to Quality Care: Ensures the organization meets rigorous standards that focus on patient safety, effective care and positive outcomes. | Both sets emphasize consistent, high-quality care built upon evidence-based practices and client/patient-centered approaches, improving outcomes and satisfaction. |
Promotes Professionalism: Following CMSA standards enhances the case manager’s credibility, competence and professionalism, building trust with clients and stakeholders. | Builds Trust and Credibility: Adhering to URAC standards enhances the organization’s reputation and trust among patients, providers and regulatory bodies. | Both emphasize credibility and trust, with CMSA focusing on individual professionalism and URAC on organizational reputation within the client community. |
Supports Ethical Decision-Making: CMSA guides case managers in making ethical decisions that prioritize clients’ rights while balancing organizational goals. | Ensures Compliance with Regulatory Requirements: URAC standards ensure organizations meet regulatory compliance, mitigating legal and ethical risks. | Ethical decision-making is key to both, with CMSA guiding individual ethics and URAC ensuring regulatory compliance to support ethics at an organizational level. |
Facilitates Coordination and Collaboration: CMSA standards help case managers coordinate care across providers and settings, ensuring continuity of care. | Improves Operational Efficiency: URAC standards streamline processes, improving coordination and reducing errors, leading to more efficient care delivery. | Both emphasize the importance of coordination—CMSA at the care management level, URAC at the organizational level to enhance efficiency and continuity. |
Reduces Liability Risks: By adhering to CMSA standards, case managers minimize legal risks through compliance with policies and professional practices. | Supports Risk Management and Safety: Ensures that organizations follow safety protocols and manage risks proactively, minimizing adverse events. | Both focus on reducing liability and managing risks—CMSA at the case manager level, URAC at the organizational level. |
Encourages Continuous Improvement: CMSA promotes ongoing education, self-assessment and staying updated with industry trends. | Drives Continuous Improvement: Promotes regular evaluations, fostering a culture of quality improvement and excellence. | Both prioritize continuous improvement, urging professionals and organizations to adapt and improve practices over time. |
Advocates for Client Rights: CMSA ensures case managers advocate for their clients’ best interests and respect their autonomy. | Enhances Patient Satisfaction and Experience: Emphasizes patient-centered care, advocating for patient rights, clear communication, and respect for autonomy. | Both stress client/patient rights and autonomy, with CMSA focusing on individual advocacy and URAC on enhancing the patient experience at a broader level. |
Source: URAC (2024) and CMSA (2024).
The Impact of Accreditation
In addition to the quality standards, URAC’s Case Management Accreditation Program is grounded in the principles of care coordination, transitions of care, patient engagement and advocacy. These principles represent priority areas for clinical case management practice. Case managers in URAC-accredited organizations have a unique perspective on how the quality standards provide the bedrock for the delivery of complex care management.
Cheri Lattimer, executive director of the National Transitions of Care Coalition and a past executive board member at URAC and CMSA affirms:
“Being a certified professional case manager and understanding the accreditation process for case management works hand in hand in highlighting the professionalism and quality of a process that supports the nurse or social worker in delivering case management services to patients and their family caregivers.”
Source: Personal communication, September 2024.
The impact of URAC’s Case Management Accreditation has been significant over the years. Applicants benefit from URAC’s third-party review process through its educational feedback loops and frequently make changes to improve how care is delivered and coordinated to patients. For example, one large system that benefited from accreditation was Blue Cross Blue Shield, which mandated that all its Federal Employee Health Plans become URAC accredited for case management soon after URAC launched the accreditation program.
URAC’s review process helps improve case management programs by assessing key activities associated with organizational governance, professional oversight and qualifications, the use of evidence-based clinical pathways, quality assurance, outcomes reporting, and much more. In addition, URAC’s review process sets quality standards for case management organizations that are aligned with the CMSA Standards of Practice.
The impact of accreditation is ultimately manifested at the patient care level. URAC asserts that organizations that have achieved accreditation for case management have demonstrated their commitment to quality care. These organizations can promote their services as being recognized against a set of national standards, as verified by an independent third-party entity. While organizations often seek accreditation to demonstrate their value to business partners, the benefits seep through the entire organization, positively impacting employees, patients and providers.
Further, accreditation benefits case management professionals because it ensures that systematic processes for learning and development are set in place. It also facilitates case managers working at the top of their license. Accreditation often leads to networking and the opportunity to learn from a wide range of experiences. When employees feel empowered in their workplace, patients and providers often see the benefits of higher quality of care and coordination among health care providers. URAC has also recently advocated for diversity, equity and inclusion (DEI), requiring organizations to determine how they promote DEI among their employees and consumers.
Today, URAC’s Case Management Accreditation program represents the 7th generation of standards and has evolved into a robust review of at least eight major areas that encompass both traditional and workers compensation case management. URAC embodies a culture of excellence and is constantly improving its standards. When asked how URAC ensures currency with emerging trends, research and approaches to case management practice, URAC responded:
“URAC has multiple avenues for staying up to date in case management practice. Our review team currently has four certified case managers who have full access to CMSA’s resources, such as journals, webinars, and continuing education units. When we perform a revision, we tap into this knowledge and have our review team members contribute to the revision process. In addition, we ensure that we include case management organizations in each revision, seeking input on how the industry has changed, what new and emerging trends are occurring, and what practices are obsolete. We encourage organizations to share best practices and learn from one another as part of the revision process, which allows us to learn from our accredited organizations and helps create a program that meets the industry’s need for recognition of quality case management programs.”
Source: URAC 2024.
The Nexus of Case Manager Certification and Case Management Accreditation
The case management community continues to establish solid certification standards for individual case managers, in addition to state nursing licensure requirements. Furthermore, case managers are leaders in their perspective fields, serving as strong proponents of organizational accreditation. The intersections of quality and standards to the practice of case management are inextricably linked. Dr. Colleen Morley (PhD), the CMSA immediate past president, highlights this interface:
“In healthcare, quality management serves as the backbone of case management, ensuring that every decision made is not just effective, but also elevates the standard of care for every individual. When quality management and case management converge, they create a powerful synergy that transforms experiences and outcomes, turning challenges into opportunities for improvement. The intersection of quality management and case management is where excellence thrives; it’s about aligning processes with purpose to deliver not just care, but compassion and dignity to those we serve.”
Source: Personal communication, September 2024.
Reflection Points
As URAC celebrates its 35th anniversary since its founding and 25 years since the launching of the Case Management Accreditation Program, a couple of thought leaders were contacted to solicit their insight and reflections on the impact CMSA and URAC have had on the field of case management. Dr. Shawn Griffin, MD, the current president and CEO of URAC, notes:
“First as a family physician and later as a population health leader, I appreciated the importance of case managers on the care team and their unique ability to help people navigate an increasingly confusing and fragmented healthcare landscape. I saw how case managers connected with patients and guided them to the right level of care while addressing the many factors outside the care environment that could either help or hurt their health. Now as the President of URAC, I appreciate having CMSA at the table as we work with many stakeholders to improve quality throughout the world of health. I look forward to many more years partnering with CMSA to learn from their unique perspective and experience while serving together to improve health.”
Source: Personal communication, September 2024.
Michael Garrett, MS, CCM, health equity and clinical consultant, who has been involved with both CMSA and URAC, notes the important of organizational standards for case management when dealing with plans sponsors:
“Most plan sponsors know that case management brings real value in coordinating care for their members with catastrophic and complex health conditions. This includes those members in a range of benefit programs, such as workers’ compensation, health plans, and disability plans. However, plan sponsors are not always sure about what features, characteristics, and capabilities they should expect from case management. Accreditation provides a framework and external validation of the integrity of the quality of case management, so that plan sponsors can feel more confident when they select a case management solution.”
Source: Personal communication, September 2024.
Moving Forward
CMSA and URAC have worked well together to create a framework for case management programs to thrive and become a core healthcare offering — with the ultimate goal of promoting better clinical outcomes. In the future, these efforts will continue to have an important influence on case managers, patients, plans sponsors and other stakeholders. Among today’s challenges, CMSA and URAC will need to address emerging trends including value-based purchasing initiatives, the impact of artificial intelligence on the practice of case management, the aging of case manager as an important group of providers, more demanding prior authorization requirements, and mental health parity requirements — just to name a few challenges and opportunities.
References
CMSA. Case Management Society of America (2024, September 18). CMSA Standards of Practice. https://cmsa.org/about/standards-of-case-management-practice/ .
CMSA. Case Management Model Act, adopted by CMSA in 2009, revised in 2017. See quick links at https://cmsa.org/advocacy/public-policy/.
URAC. Utilization Review Accreditation Commission (2024, September 18). Case Management and Workers’ Compensation Case Management Accreditation v7.0. https://2297879.fs1.hubspotusercontent-na1.net/hubfs/2297879/CMv7-SAAG09262022.pdf.
Garry Carneal is a leading expert in healthcare. He has researched, written and published extensively on quality, medical management, information technology and regulatory trends. Garry is best known for his work in the accreditation field where he has spearheaded and launched 30 accreditation programs since 1996. Currently, Garry heads up Schooner Strategies, based in Annapolis, MD, which provides an array of consulting and management services; serves as the president & CEO of RadSite, which offers accreditation programs for advanced diagnostic imaging; advises the Autism Commission on Quality, which accredits applied behavior analysis programs for the treatment of individual with autism; and runs the Physicians for Medicare Advantage Beneficiaries, a nonprofit provider coalition which is trying to improve reimbursement rates and the levels of care for seniors. Previously, Garry served as the president and CEO of URAC and expanded the organization from one accreditation to 17 during his nine-year tenure. He also has been a volunteer and member with CMSA since 1998.
Dr. Melanie Prince (Ed.D) is a retired Air Force Colonel. Her military career was one marked by great accomplishment. From the creation of the Air Force’s first-ever independent nurse managed clinic — solely staffed by nurse case managers to provide a setting for data-informed population health and disease management — to the development of policy, educational programs and toolkits for case management clinicians, Melanie continues to make an impact through her service as an executive leader for medical management, case management, utilization management, disease management, discharge planning and health benefit programs. Her leadership and operational skills are complemented by her profound clinical insights, particularly in executive nursing and case management. Melanie’s approach has always been to integrate case management with best business practices to deliver accessible, cost-effective, and quality healthcare. Melanie is a past president of CMSA, and she currently serves on the URAC Board of Directors, CMSA Foundation and the Centers for Medicare & Medicaid Services Advisory Panel on Outreach and Education.
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