Case Managers and Accreditation: The Current Situation - Jan Harrison, Joanna Collins & Niccola Irwin, Harrison Associates
18/10/13. The authors, senior occupational therapists and case managers with Harrison Associates, consider the need for accreditation of case managers in the United Kingdom. They look at the evolution of the role of case manager, the role and function of a case manager, the current lack of a formal accreditation regime and conclude that formal accreditation is something that should be encouraged and welcomed.
Introduction
Case management has a relatively short history in the United Kingdom with services as yet unregulated. Case management cannot be correctly described as a profession but is working steadily towards this status. Indeed “case manager” remains an unprotected title and the professional status of case managers working with clients following catastrophic or complex injuries rests upon their existing qualifications in other health fields.
The difficulty in defining the broad remit of case management finds a parallel with a similar attempt to define “rehabilitation”. It is from the broad perspective of rehabilitation as a response to injured individuals that case management emerges. The Case Management Society UK (“CMSUK”) defines case management as:
“a collaborative process which assesses, plans, implements, co-ordinates, monitors and evaluates the options and services required to meet an individual’s health, care, educational and employment needs, using communication and available resources to promote quality cost effective outcomes.”1
In this article, we first consider the historical background for the current situation with regard to the standing of case management in the United Kingdom. We discuss the existing professional status of the individual case manager who works with clients following catastrophic and complex injuries. We appreciate that there are many different types of case management but this is the work that we know and undertake ourselves at Harrison Associates. We then outline existing opportunities for the accreditation of the company providing case management services. The organisations that exist to represent case managers are continually developing pieces of work that can help to establish better structure for the case management field. Included in this is recent research conducted by CMSUK concerning professional recognition, registration and educational pathways for case managers. This important research is summarised as part of our consideration of the future of case management in the United Kingdom.
History and context
Case management has been known for many years longer in other countries such as the United States, Australia and Sweden, where there are differing health services. Case management began slowly in the United Kingdom, mainly through health professionals becoming involved in helping claimants undergoing a compensation claim. In common with the emergence of other health professions here, case management began to organise itself by responding to a need for networking and communication with others practising the same work, before gradually building membership groups who then recognised the necessity to start to codify the nature of the work. Over time, these groups expanded their membership, and began to develop committees, boards and subgroups able to focus on specific issues of interest or concern to members. Currently the main membership bodies which represent and support the practice of case managers are the British Association of Brain Injury Case Managers (“BABICM”), the Case Management Society UK (“CMSUK”) and the Vocational Rehabilitation Association (“VRA”) all of whom are involved to greater or lesser degrees in developing guidelines, standards and latterly, codes of ethics.
There are companies who use the title “case manager” for those without previous healthcare qualifications who work with clients with minor injuries. The title is also used loosely within some mainstream health and social care provisions where a particular professional acts as a care coordinator or key worker. There are other anomalous usages of the title and the inclusion or otherwise of those who use this designation in various other fields may become moot issues should the title of case manager become protected. Despite this, protection is necessary for the safeguarding of the vulnerable clients with whom most case managers work.
Case managers working with clients following catastrophic and complex injury come from diverse health professional backgrounds, although the majority are from the occupational therapy, nursing and social work professions. Within the profession of occupational therapy, for example, case management falls under the broad description of an area of “extended scope of practice”.2 Each professional body has its own existing standards, and the professionals are required not only to work to those standards but to be registered with the relevant regulatory body (Health and Care Professions Council for occupational therapists and other health professionals, the Nursing and Midwifery Council for nurses, and the General Social Care Council for social workers) to be able to practice in the United Kingdom. The standards and guidelines written so far for case managers are drawn from the spirit of these existing professional standards, and in fact the CMSUK Standards were based on those of the College of Occupational Therapists. BABICM Standards and Guidelines is a set of advice written specifically for case managers working with clients following acquired brain injury. However, there is no regulatory body with whom the case manager can officially register or to whom they are accountable as a case manager.
The individual case manager
The independent status of case managers is key within injury cases, and their professional background is considered to underpin and inform their judgement. Most of the various professional bodies from which case managers come implement a continuing professional development framework with expectations that the individual health professional takes responsibility for ensuring their practice is in line with current knowledge and trends particular to their profession. There are, however, many skills and knowledge areas that are specific to case management and currently gained only through mentorship, supervision and experience within the field. The authors understand that BABICM has formulated competencies for case managers working with clients with brain injury, and this is a welcome start to the defining of the role and knowledge base of those practising in the field. CMSUK has developed a Continuing Professional Development programme to help case managers establish their credentials and to encourage thoughtful collation of their experience.3
There is a paucity of training specifically for case managers with professional backgrounds who wish to pursue a higher level of qualification, although some short courses at varying academic levels are available. For the most part, however, case managers have to rely on finding their own ways of gaining skill, usually by working with other, more experienced case managers within an established company. There can be many negative consequences for clients, and commissioners, if the case manager proves to be unskilled and ineffective, as many have learned to their cost.
Until qualifications specific to case management become commonplace, it is incumbent upon the purchaser of case management services to ask those questions which identify whether an individual case manager is suitable to manage the case in question. In some instances, perhaps more so if a case manager is working independently as a sole trader, it would be fair to warn, “buyer beware”. After viewing the case manager’s CV and terms and conditions of trading, the next step would be to check their current professional registration. It would be helpful to ask the potential case manager if they work within a framework where they set goals for rehabilitation and implementation of support for the client. In discussion it should be possible to ascertain whether a case manager practises in a manner which is client-centred in principle.
The case management company
In terms of reputable case management companies, there is a move towards companies in the United Kingdom seeking accreditation. We acknowledge that at this time for most companies in this relatively new field there will be a period during which accreditation is being sought but has not as yet been awarded. But without case management specific accreditation in the United Kingdom, where do case management companies turn to seek such recognition of good practice standards?
Case management for catastrophic and complex cases is now considered an activity akin to rehabilitation and certainly espouses the same core principles. It is natural, therefore, when first seeking an appropriate accreditation or quality mark to look to the world of rehabilitation for this.
One of the first pieces of work for the newly established United Kingdom Rehabilitation Council (“UKRC”) was to establish broad standards of service. The UKRC published their Rehabilitation Standards in 2009 aimed at educating commissioners and service-users in helping them to choose an appropriate rehabilitation service.4 These standards formed the basis for the British PAS1505 code of practice for rehabilitation services. Although both set out good practice for rehabilitation services, neither of these are regulatory standards, or specific to the practice of case management.
Quality marks such as ISO 9001 (“International Standards Organisation”) reward organisational success through the lens of excellence in business practices. The organisation describes ISO 9001 as using:
“generic management system standards ... the same standard can be applied to any organisation, large or small, whatever its product or service, in any sector of activity, and whether it is a business enterprise, a public administration, or a government department.”6
As such they use a model suitable for business systems accreditation and do not use measures specific to rehabilitation or case management services. The Care Quality Commission (“CQC”) is known to many and is a regulatory body for health and social care services in England to ensure they meet prescribed standards.7 Again, these standards do not address the broad range of activities which fall within the scope of case management.
The Commission on the Accreditation of Rehabilitation Facilities (“CARF”) is an accreditation body with an extensive and growing international remit.8 As such it is being looked to as a suitable quality assurance framework for case management companies and their services. The standards match the functions of the case management company more closely in that they focuses on clinical and rehabilitation activities in addition to solid business practices. It may therefore be a preferred framework for case management companies in the United Kingdom.
CARF certification is awarded on the basis of the principles of progress in rehabilitation. It contains standards in overall business practice, case management, medical rehabilitation and specific categories for those working with children or working with clients following spinal cord or brain injury. The function of the audit processes, once implemented, is to sustain a quality culture within the organisation while clearly expressed standards provide the measure by which successful implementation of these processes are judged. Demonstration of compliance is not the primary intention of these checks and balances, but rather the establishment of continuous quality improvement sustained over the period between the external audit events. At the outset the requirements central to the accreditation process will necessitate a certain amount of reorganisation and restructuring of service delivery within a company. This can seem a daunting, expensive and time consuming prospect for the typically small service provider but the benefits of implementing CARF accreditation and the ensuing quality outcomes are well documented.9
Many case management companies provide additional services. For example, these may include expert witness services, therapy services, or in-house employment of carers for both case managed clients and other customers including state run facilities. The range of services offered affects the type and level of accreditation sought. Thus a company that specialises in providing case management as an adjunct to care worker provision is initially likely to register and seek accreditation from a body such as the CQC. Indeed, eventually, a company may register with more than one accreditation body in order to reflect the range of services offered.
There is considerable variety among companies offering case management services and accreditation is not yet in progress for most of these. We consider that in the meantime there should be existing quality oversight in any such company and suggest the following guidance for purchasers as to the hallmarks of a bona fide company. At core, whether accredited or not, the company should engage professionally able case managers and work within an authentic company structure based on sound principles of rehabilitation. The UKRC provides its online members with written guides for purchasers and consumers of rehabilitation services.10 Beyond these more general standards the service user and commissioner should expect there to be a culture of proactive case management including regular and clear communications, client-centred practice, and achievable goal setting with financial transparency. It is clear that some case managers have greater experience than others and in the absence of a specific case management qualification it is reassuring for a purchaser to know that a case manager has access to regular supervision by seniors and peer support. It is also important for there to be redress and a structured format for feedback or complaint for the service user or commissioner if there is a problem. It is also possible to check the company registration to verify their bona fide status with Companies House.
The future
Case management services remain unregulated and this is a situation that will need to be remedied in the coming years. It is a constant complaint from commissioners that it is difficult to identify case managers who can be relied on to do the right thing, in the right way, at the right time. At present the whole field tends to rely on “who you know” and who has been tried and tested in the past. If problems do occur, there is no system for deregulating a case manager who is free to continue bad practice. Naturally it takes time and broad consultation to establish how the regulation of the industry might be achieved. It is heartening that several companies are exploring accreditation. There are, however, other elements in the establishment of a new profession, and formal registration has to rely on there being agreed criteria for good practice, a consensus on the knowledge base, and a way of recognising that a certain level of skill has been achieved. This requires a designated educational framework or formal pathway, full registration with a regulatory body rather than simply membership of an organisation, and the recognition and protection of title.
Recent research has been completed by CMSUK exploring the need for and the nature of a formalised educational pathway through case management.11 The research was based on the belief that this would underpin the other requirements for the affirming of professional standing.
An online survey was carried out with a mix of providers and commissioners of case management services with a greater number of the former.12 95 per cent of respondents had a professional qualification and a high proportion work in the private sector. The responses indicated that professional recognition, registration and qualification was supported. A significant majority agreed that an accredited pathway for case managers was needed. 53 per cent of respondents agreed that a specific case management qualification was necessary, although there was more concern about this amongst the longer standing practitioners, an understandable response from those who may be worried about having to sit exams to practice in a field in which they have worked successfully for many years. It is clear that case managers themselves wish to be more formally recognised and have some form of control in their professional status.
There were further details mentioned in this project concerning the implementation, scope and content of an educational pathway for case managers, and further debate around these issues will be forthcoming. It would seem from the tenor of this research that the development of an academic, clinical training for individuals to become case managers without necessarily previously having a professional qualification is unlikely to be a priority. It is more probable that the main focus will be on the expansion and formalisation of courses and in-service training for those who have an existing professional background and experience. The recommendations from the research raise more questions as to the model to be used for defining case management as a whole. Clearly it will be essential to explore and debate the nature and parameters of the emerging profession of case management before establishing a coherent educational pathway. Further investigation into how other countries have fared with this endeavour is recommended. The findings from the research are currently on the CMSUK website.13 The Board of CMSUK has recently agreed that this important work should progress based on the recommendations, and for the committee charged with the work to include a full range of stakeholders.
The field of case management looks forward to the time when those seeking such services for the injured client can be reassured that a case management company has been through a rigorous accreditation process and secured a meaningful quality mark, and that individuals working as case managers are thoroughly trained and supervised and operate within a strong professional structure. This extends beyond those case managers working with clients involved in a compensation claim, reaching to the widest remit of this rapidly developing field, to ensure best practice in supporting and protecting vulnerable clients to achieve better outcomes and live their lives to the fullest.
1 Case Management Society of the UK (“CMSUK”), Standards of Practice (Reading: CMSUK, 2007).
2 College of Occupational Therapy (“COT”), Briefing 14: Extended Scope Practice (London: COT, 2009).
3 Case Management Society of the UK (“CMSUK”), 2011, CPDoL Launch at http://www.cmsuk.org/NewsItem.aspx?NewsID=249 [Accessed July 29, 2013].
4 United Kingdom Rehabilitation Council (“UKRC”), Rehabilitation Standards: hallmarks of a good provider (London: UKRC, 2009) at http:/ /member.rehabcouncil.org.uk/UKRCMember/secure/Downloads.aspx [Accessed July 29, 2013].
5 British Standards Institute (“BSI”), PAS 150 Providing Rehabilitation Services: Code of Practice (2010).
6 International Standards Organisation (“ISO”), Discover ISO: What’s different about ISO 9001 and ISO 14001? (2012) at http://www.iso.org/iso /about/discover-iso_whats-different-about-iso-9001-and-iso-14001.htm [Accessed July 29, 2013].
7 Care Quality Commission (“CQC”), The Scope of Registration (London: CQC, 2009).
8 Commission on the Accreditation of Rehabilitation Facilities (“CARF”) (2012) at http://www.carf.org/Providers/ [Accessed July 29, 2013].
9 W. L. Nicklin, T. McLellan and J.A. Robblee, “Aim for excellence: Integrating accreditation standards into the continuous quality improvement
framework” [2004] Healthcare Quarterly vol.7 issue 4, 44–48, V. L. Ripley, Fostering an Environment of Continuous Quality Improvement. Research paper (Canda: Royal Roads University Victoria, 2007).
10 United Kingdom Rehabilitation Council (“UKRC”), PAS 150—Groundbreaking specification for rehabilitation service providers is launched (London: UKRC, 2010) at http://member.rehabcouncil.org.uk/UKRCMember/Secure/NewsDetail.aspx?ID=47 [Accessed July 29, 2013].
11 Case Management Society of the UK (“CMSUK”), An Investigation to identify the need for a Standardised, Accredited or Certified Professional Pathway for Case Managers in the UK (Reading: CMSUK, 2012) at http://www.cmsuk.org/userfiles/0000%20HT%20Report%202012.pdf [Accessed July 29, 2013].
12 Case Management Society of the UK (“CMSUK”), An Investigation to identify the need for a Standardised, Accredited or Certified Professional Pathway for Case Managers in the UK (Reading: CMSUK, 2012).
13 Case Management Society of the UK (“CMSUK”), An Investigation to identify the need for a Standardised, Accredited or Certified Professional Pathway for Case Managers in the UK (Reading: CMSUK, 2012).
First published in the September 2013 Journal of Personal Injury Law (Thomson Reuters).
Authored by Jan Harrison, Niccola Irwin and Joanna Collins
of Harrison Associates, which was CARF*-accredited for the
maximum three years in May 2013 for the high quality of its
rehabilitation services.
*CARF is the Commission on the Accreditation of Rehabilitation Facilities.
Image ©iStockphoto.com/IuriiSokolov
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