Across the health and human services spectrum, professional case managers practice under a broad umbrella of guidance composed of two separate, yet highly complementary, documents: the Case Management Society of America's (CMSA) Standards of Practice for Case Management (CMSA, 2016) and the Commission for Case Manager Certification's (CCMC) Code of Professional Conduct for Case Managers (CCMC, 2015). The purpose of this jointly authored column is to showcase the complementary nature of the Standards and the Code, while highlighting the uniqueness of each.
Although the Standards include an ethics discussion, and the Code covers practice standards, the overlap between the documents is minimal and purposeful. Most important, they are not in conflict with one another. Case managers need to follow the Standards and operate under the Code. Together, these documents provide foundational knowledge for case managers in every practice setting and ethical guidelines for addressing conflicts and dilemmas that often confront case managers in today's fragmented and highly complex health care environment.
The Standards, which were introduced first in 1995 and most recently revised in 2016, address the practice of case management in the context of today's focus on the consistent delivery of quality health and human services, as well as the high cost of delivering those services. The Standards are meant to standardize the case management process and depict the scope of case management to colleagues, employers, consumers, legislators, policymakers, and other stakeholders who partner with the professional case manager (CMSA, 2016).
The Standards recognize that professional case management is not a linear process. The phases of assessment, planning, facilitation, care coordination, and evaluation are fluid and can be revisited if they need to be readdressed to provide options and services to meet an individual's and family's comprehensive health needs. In determining goals with the individual and family, the case manager acts first and foremost as an advocate. Through communication and collaboration, available resources are identified to promote patient safety, quality of care, and cost-effective outcomes. Throughout this process, case managers work closely with members of a broad interdisciplinary team that typically includes physicians, nurses, and other clinicians and health care professionals, always keeping at the center of the case management process the “client” (the individual receiving case management services).
Per the Standards of Practice, the role function of a professional case manager includes “advocating for both the client and the payer to facilitate positive outcomes for the client, the interprofessional health care team, and the payer. However, when a conflict arises, the needs of the client must be the number one priority” (CMSA, 2016, p. 17).
While providing advocacy for the client and his/her family, “professional case management fosters the careful shepherding of health care dollars while maintaining a primary and consistent focus on quality of care, safe transitions, timely access to and availability of services, and most important client self-determination and provision of client-centered and culturally-relevant care” (CMSA, 2016, p. 5). To assume these tasks and responsibilities, case managers must have an academic discipline in a health or human service discipline; possess a current, active, and unrestricted license or certification; have a baccalaureate or graduate degree in a health or human services field; be able to function independently in the scope of practice of his/her discipline; and demonstrate current knowledge and competence to provide holistic, client-centered care (CMSA, 2016). These criteria are highly important in the health care environment today, in which the terms “case manager” and “case management” are sometimes erroneously applied to people involved in administrative functions and who are not practicing professional case management (Jensen & Zawalski, 2018).
By reviewing the Standards, case managers gain a deep understanding of the scope of case management practice. At every juncture, the philosophy and guiding principles of case management apply, as described by the Standards: “Case management interventions focus on improving care coordination and reducing the fragmentation of services the recipients of care often experience especially when multiple health care providers and different care setting are involved” (CMSA, 2016, p. 12).
The case manager should promote the client's self-determination, informed and shared decision-making, autonomy, growth, and self-advocacy. The CMSA's Standard for Ethics state the professional case manager should behave and practice ethically and adhere to the tenets of the code of ethics that underlie her/his professional credentials. Awareness of the five basic ethical principles and how they are applied are essential. These principles include beneficence, maleficence, autonomy, justice, and fidelity (CMSA, 2016, p.28).
The Code of Professional Conduct for Case Managers was originally adopted in 1996 as a means to assure quality in case management and protect the public interest. Most recently, it was revised in two parts. In January 2014, the governing procedures for hearing ethics complaints were approved by the CCMC. Review and revision of the body of the Code, encompassing the principles, rules, and standards of conduct, were completed in January 2015. Updates to the Code include protecting patient privacy and information in today's digital era.
The Code does not address every case management challenge or situation, nor is it meant to. Rather, it provides ethical guidelines and principles, while leaving the day-to-day practice decisions to the judgment of the case manager. Said another way, the Code outlines the responsibility but does not tell the case manager how to fulfill that responsibility. It is best thought of as a framework for case managers, particularly those who are board-certified as Certified Case Managers (CCMs).
Core principles in the Code include putting the public interest above one's own and respecting the rights and inherent dignity of the client. Advocacy for clients comes before a case manager's other loyalties, including responsibility to one's employer (CCMC, 2015). Sometimes this presents a challenge for the case manager who wants to fulfill obligations to his/her employer (i.e., an insurance company, hospital, or other organization directly impacted by the cost of care) but believes that advocacy for the patient requires additional resources that have not been approved. Faced with these conflicts, the case manager can find direction in the Code, including specific citations to give to one's employer, supervisor, or colleagues.
Another ethical challenge frequently encountered in acute care is how to advocate both for the client whose insurance covers multiple treatment options and for the client who is uninsured and cannot pay to access the same health care resources. There is disparity in access to health care, but the case manager must be an advocate in both cases. In the latter case, the case manager must strive to find a payer source or other means to access the necessary resources, if at all possible.
The Code acknowledges that conflicts such as these will arise in the course of carrying out case management duties. “Because case management exists in an environment that may look to it to solve or resolve various problems in the health care delivery and payor systems, case managers may often confront ethical dilemmas. Case managers must abide by the Code as well as by the professional code of ethics for their specific professional discipline for guidance and support in the resolution of these conflicts” (CCMC, 2015, p. 4). By adhering to the Code's principles, rules of conduct, scope of practice, and standards for board-certified case manager conduct, professional case managers gain the assurance that they are practicing ethically. They understand that encountering ethical dilemmas and gray areas in their daily practices does not indicate any wrongdoing or questionable decisions or actions; rather, it is more likely to be assurance that they are practicing in the “real world” of today's health care with an awareness of red flags and conflicts among stakeholders (Sortedahl, Mottern, & Campagna, 2018).
Like the CMSA Standards of Practice, “underlying values” of case management as outlined in the Code compel case managers to “understand that case management is guided by the ethical principles of autonomy, beneficence, nonmaleficence, justice, and fidelity” (CCMC, p. 4). These values hold case managers to respect others' rights to self-determination; to do good and to help others; and to keep commitments or promises (CCMC, p. 5). At the same time, the Code, like the Standards, urges the case manager to work collaboratively with others in support of the goals of the client, particularly through such challenges as transitions of care.
Standards and Code: Hand-in-Hand
The responsibilities of today's case managers are broader than ever, among them to measure and evaluate outcomes. The expansion of the case manager's role is often accompanied by a larger caseload as well, but with the same expectation of advocacy for each individual. Fortunately, case managers do not have to go it alone. Support, guidance, and resources are available to case managers in the form of the Standards and the Code, which reflect the collective knowledge of the practice and two leading organizations—CMSA and CCMC—dedicated to furthering excellence among case managers across the health and human services spectrum. As Helen Keller said, “Alone we can do so little, together we can do so much!”
Kathleen Fraser, MSN, MHA, RN-BC,
Executive Director, Commission for
Case Manager Certification
Vivian Campagna, MSN, RN-BC, CCM
Chief Industry Relations Officer, Commission for
Case Manager Certification