Preparation of rehabilitation counselors for case management practice in health care settings.

The American health care system and the insurance industry are currently undergoing significant reforms in order to rein in the high cost of delivering health care services in this country. Managed care is considered the cornerstone of the new health reform age (Choppa, Shafer, Reid, & Siefker, 1996; Strickland, 1995). The case management industry with its focus on cost containment, managed competition, and quality care is playing an increasingly important role in the managed care environment (Mullahy, 1995; Owens, 1996). According to Mullahy (1995), the number of case managers has risen from an estimated five to ten thousand in 1985 to a total of fifty to one hundred thousand today. These individuals come from diverse training backgrounds and practice settings that include nursing, rehabilitation counseling, and social work. Presently, there are 19,000 Certified Case Managers (CCMs) (E. Holt, personal communication, October 22, 1996).

The role of case managers is to facilitate the delivery of cost-efficient individualized and coordinated care to patients afflicted with chronic illnesses and disabilities in today's technologically advanced medical environment. Case management is a disciplined application of skills, tools, and techniques that facilitate positive movement toward a desired outcome. Specifically, case management can be defined as a "collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs through communications and available resources to promote quality, cost-effective outcomes." (Mullahy, 1995, p. 9).

Recently, Leahy (1994) surveyed 14,078 CCMS to empirically validate the common knowledge dimensions required for case management practice. He developed a 132-item knowledge importance instrument based on a comprehensive review of the literature, an inspection of 500 job descriptions of case managers, and the recommendations of 30 content experts. Because case management is practiced in a variety of settings by many different professionals, only items which attained a mean importance rating of 3 or higher (0=not important, 1=little importance, 2=moderate importance,(3=highly important, 4=essential) were included in a principal component analysis to determine the underlying knowledge dimensions for case managers in all settings. He found five knowledge domains to be important to case management practice: coordination and service delivery, physical and psychosocial aspects, benefit systems/cost benefit analysis, case management concepts, and community re-entry. The internal consistency reliability coefficients of these five factors were found to range from .86 to .93. Although case management is practiced in a variety of settings and by many different professionals, his research suggested that CCMs do share common core of knowledge areas required for effective case management practice.

Increasingly, registered nurses and rehabilitation counselors are being hired to fill the function of case managers in the disability/health care marketplace. Although Leahy (1994) identified several universal knowledge domains that are essential for case management practice across settings, those familiar with case managers frequently note that there appears to be some differences in function and emphasis among case managers drawn from different disciplines (Choppa et. al., 1996). It then becomes important to determine whether there are knowledge domains specific to the professional specialization of the case managers, such as case managers with a rehabilitation counseling background. The purpose of this study is to determine the universal and specific knowledge domains perceived by rehabilitation counselors as important to case management practice in today's disability/health care settings. Most importantly, we are interested in determining the degree of reported preparedness of rehabilitation counselors to perform the case management functions identified in this study.

Method

Participants

The sample for this study consisted of a subset of the Leahy (1994) sample. Leahy's original sample consisted of 11,109 case managers who returned his Certification for Case Manager Questionnaire (CCMQ). These participants are individual case management practitioners who applied for the Certified Case Manager credential and met the eligibility requirements for certification during the period September 1992 through July 1993. Of these 11, 109 participants, 1,208 identified themselves as rehabilitation counselors engaged in providing case management services. The responses of these 1,208 individuals on the CCMQ were extracted for the purpose of this study.

Of these 1,208 respondents, 859 (71.1%) were women and 349 (28.9%) were men, with an average of 10.1 (SD = 5.7) years of work experience. The mean age of the participants was 42.4 (SD = 10.1). The majority (87.8%) of the participants were white. The most frequent work settings reported by the participants were: (1) independent rehabilitation/insurance affiliates (38.1%); (2) independent case management companies (36.8%); (3) workers' compensation insurance companies (4.3%); (4) federal/state agencies (3.7%); and (5) rehabilitation facility programs (3.7%). This distribution reflects a predominantly insurance-related practice arena.

Instrument

The Certification for Case Manager Questionnaire (CCMQ) was specifically designed to validate the knowledge standards for certified case managers. The CCMO consists of 132 case management knowledge items. Content validity of the CCMO was established by a comprehensive review of the literature and a thorough review of 500 job descriptions of case managers secured during the application phase of the CCM credential. Initially 400 research items were constructed to reflect the potential knowledge areas required. These knowledge statements were then revised for redundancy and clarity by an independent test construction consultant. Subsequently, the CCMO was reviewed by a panel of 30 content experts. These experts provided feedback on the developed items, suggested deletions, and developed additional knowledge areas not reflected in the original items pool. Based on their feedback, the number of items were pared down to 132 items.

Two 5-point, Likert-type scales were used with each of the 132 items to assess IMPORTANCE of the knowledge areas to the respondent's role as a case manager and the PREPAREDNESS of how the respondent feels in each of the knowledge area as a result of education and training. Possible ratings for the importance scale are 0 = not important, 1 = of little importance, 2 = of moderate importance, 3 = highly important, and 4 = very highly important. Correspondingly, possible ratings for the preparedness scale are 0 = no preparation, 1 = little preparation, 2 = moderately prepared, 3 = highly prepared, and 4 = very highly prepared. The importance scale was used in this study to examine case management knowledge areas that are perceived to be important for rehabilitation counselors in proprietary settings and the preparedness scale was used to determine participants' reported mastery of the knowledge domains.

Research Design and Data Analysis

The research design for this study included descriptive and ex post facto approaches. The descriptive approach involved (a) the use of factor analysis to examine the factorial structure underlying knowledge areas perceived by the rehabilitation counselors with the CCM credential in this study as essential to case management practice; and (b) an examination of the mean perceived importance and reported preparedness of the participants on these empirically derived knowledge dimensions. The ex post facto portion of the study included comparisons of the rehabilitation counselors by employment settings on those empirically derived knowledge domains in terms of their relative importance and perceived preparedness to perform those case management functions.

Results

Factor and Item Analyses

Using a cross-validation approach, the participants were randomly assigned to two groups based on a 60/40 split. The first group (n = 725) was used as the derivation sample and the remaining group (n = 483) was used as the cross-validation sample. Common factor analysis (or principal factor analysis) was used to determine the dimensionality of the CCMQ. Common factor analysis techniques were preferred over principal component analysis because recent research (c.f., Clark & Watson, 1995; Floyd & Widaman, 1995; Smith & McCarthy; Widaman, 1993) has indicated that factor loading estimates based on common factor analysis generalize well to those estimates observed using confirmatory factor analytic techniques. Common factor analysis also produces more accurate final estimates of communality than does principal components analysis. Floyd and Widamen (1995) in their article summarizing guidelines for using factor analysis in the development and refinement of measuring instruments stated that "clearly, common factor analysis techniques should be strongly preferred over component analysis techniques for most research applications that attempt to understand a domain of phenomena in terms of a smaller number of underlying, latent variables."(p.291).

Using only responses from the derivation sample, a series of factor analyses and item analyses were computed to arrive at an optimal solution of CCMQ items. In the first factor analysis, the 132 knowledge items were intercorrelated using the product-moment method. The resulting intercorrelation matrix was factor analyzed using the principal-axis method. The Kaiser-Guttman rule (eignevalue greater than one) and Cattell's scree test were used to determine the number of factors to be retained (Cattell, 1966; Gorsuch, 1983). A five-factor solution was indicated and rotated using the varimax rotation. Following the suggestions of Clark and Watson (1995), items that load weakly (factor loadings [less than] .40) on all factors were deleted from further analyses. A series of item analyses were computed to examine the internal consistency of each subscale using coefficient alpha and the average interitem correlation as measures of internal consistency.

The inclusion of the average interitem correlation as a measure of internal consistency is recommend for scales with a relatively large number of items (such as the CCMQ used in this study). This is because the average interitem correlation is not affected by the number of items whereas coefficient alpha will become artificially inflated with a large number of items (Cortina, 1993; Clark & Watson, 1995). Clark and Watson (1995) recommended that the average interitem correlation fall in the range of .40-.50 for factors representing a specific domain with 15 or more items. In our study, additional items were deleted until the average interitem correlation for each subscale fell to the range of .40-.50 and the alpha coefficients were greater than .85. Using these procedures, a total of 83 items were retained for the final common factor analysis. The resulting five-factor solution (which accounted for 51.1% of the total variance) was parsimonious, had good simple structure, and could be meaningfully interpreted. In order to assess the stability of the derived factor structure, a common factor analysis was also computed for the cross-validation group, using the same 83 CCMQ items. A five-factor solution (accounting for 51.1% of the total variance) was also indicated and rotated using the varimax rotation.

The correlations between each of the factor pair derived from the derivation and cross-validation samples were computed using the coefficient of factor similarity (CFS) approach suggested by Kaiser (Gorsuch, 1983; Kaiser, 1960; Kaiser, Hunka, & Bianchini, 1971). The CFS approach requires knowledge of the basic factor matrices from two analyses. CFS methodology equates the origin and factor-vector orientation of two factor structures, and then determines analytically the degree of rotation in hyperspace of the factor axes of one of the structures which will maximize the degree of overlap between corresponding variable vectors. The degree of rotation necessary to achieve this criterion is expressed as a matrix of cosines of the angles between all pairs of factor axes in the two structures being assessed for similarity. These cosines can be interpreted as correlations between the factors derived from the two analyses, although not in the Pearsonian sense (Hedl, Chan, & Kwok, 1993). The PC-Relate program was used for the computation (Hedl et al., 1993). PC-Relate is a personal computer version of the Kaiser CFS approach as originally programmed in FORTRAN by Veldman (1967).

The correlation coefficients for the factor pairs expressed in cosine values were: .997, .991, .995, .993, and .994 respectively. According to Vagg and Hammond (1976), cosine values of .985 and above yield axes that are "identical." It can be concluded that all five factor pairs in the two analyses are identical, suggesting that the dimensionality findings and instrument properties of the CCMQ are stable and should be replicable on independent samples. As a result, the responses of the two samples were combined for subsequent analyses.

Knowledge Domains Derived from Factor Analysis

The mean perceived importance and reported preparedness of individual items constituting each of the five knowledge domains are presented in Tables 1 and 2. Table 1 Knowledge Domains Underlying Case Management Practices for the Rehabilitation Counselor Sample (N=1208)

Knowledge Domain                                         M       SD

Medical Treatment Modalities and Services (Alpha=.95)   2.81    0.68

121. levels of care in the acute phase.                 2.62    1.07
87.  competitive costs for medical/health care
     services.                                          2.62    1.00
122. levels of care in the chronic phase.               2.86    0.97
70.  how to analyze health care plans for               2.77    1.06

71.  how to assist individuals with the development of  2.98    2.98
     short- and long-term health goals.
124. how to acquire the necessary data to determine
     the                                                2.77    1.02
     cost of care.
123. how to identify cases that would benefit from      2.81    0.96
     alternative care.
83.  pharmaceutical and pharmacological management.     2.49    1.02
117. how to facilitate the implementation of medical.   2.96    0.94
     directives
73.  health care delivery systems.                      2.85    0.94
69.  how to negotiate rates to maximize available       2.42    1.20
     funding for an individual's health care needs.
94.  how to assess clinical information to develop      3.14    0.88
     treatment plans.
97.  available treatment modalities.                    3.13    0.85
120. how to obtain needed medical supplies.             2.91    0.96
85.  the principles of health care maintenance.         2.45    0.95
63.  home health resources.                             2.55    1.02
95.  how to establish treatment goals that meet the     3.34    0.85
     client's health care and safety needs as well as
     referral requirements.
68.  how to act as an advocate for an individual's      3.05    0.89
     health care needs.
86.  scope of practice of health care providers.        2.74    0.89
115. the disease process of medical illness.

Community Resources and Services (Alpha=.95)            2.34    0.72
130. suicide prevention.                                2.58    1.13
16.  Medicaid provisions.                               1.73    1.20
64.  community-based funding resources.                 2.45    1.02
62.  resources for residential care.                    2.22    1.08
103. standard treatment protocols for psychiatric
     illness.                                           2.50    0.97
128. eligibility for community-based services.          2.64    0.93
102. treatment resources for chemical dependency.       2.76    0.89
17.  Medicare provisions.                               1.81    1.20
129. crisis intervention.                               2.78    1.02
77.  the philosophy of hospice and palliative care.     1.90    1.16
40.  the process/procedure for determinations of        2.01    1.06
     mental competency.
90.  the reporting requirements for health care         2.02    1.21
     reimbursements in the public sector.
88.  competitive costs for independent living.          2.16    1.12
75.  how to determine respite needs of caregivers.      2.06    1.13
74.  how to determine respite needs of individuals.     2.11    1.09
59.  eligibility for services in the public sector.     2.77    0.94
35.  legal reporting requirements for abuse.            2.37    1.13
60.  procedures for referral in the public sector.      2.73    0.94
116. the disease process of psychiatric illness.        2.66    0.95
104. the philosophy of Holistic medicine.               2.13    1.03
65.  legal resources for individuals.                   2.31    0.98
105. treatment modalities of Holistic medicine.         2.10    1.05
101. signs and symptoms of chemical dependency.         2.94    0.83

Professional Judgement and Problem Solving (Alpha=.92)  3.30    0.49

126. restrictions on the release of confidential        3.49    0.72
     information.
113. how to communicate case objectives to those who    3.50    0.66
     need to know.
108. how to establish working relationships with        3.47    0.67
     referral sources.
125. legal and ethical issues pertaining to
     confidentiality.                                   3.53    0.70
53.  planning and goal development techniques.          3.35    0.74

46.  how to apply problem-solving techniques to the     3.50    0.68
     case management process.
47.  the role of the case manager.                      3.58    0.64
119. adaptive equipment needed for persons with         3.13    0.82
     disabilities.
131. how to make referrals for assessments.             3.23    0.76
118. assistive devices needed by persons with
     disabilities.                                      3.13    0.81
106. how to obtain an accurate history.                 3.50    0.70
48.  case management philosophy and principles.         3.26    0.79
82.  psychological characteristics of disabling
     conditions.                                        3.23    0.76
127. the principles of informed consent.                3.25    0.87
49.  how to evaluate the effectiveness of case          3.14    0.81
     management.
43.  how to identify predictors of outcomes of case     2.98    0.87
     management services.
57.  how to develop the critical competency of case     3.19    0.82
     management plans that address the individual's
     needs.
107. how to establish a disabled client's support
     system.                                            3.11    0.83
44.  how to determine the benefits an individual
     derives                                            3.05    0.83
     from case management services.

Cost Containment (Alpha=.89)                            2.43     .73

13.  procedures of cost analysis.                       2.37    1.05
2.   cost containment strategies that maximize an       2.67    0.98
     individual's access to funding.
11.  procedures to access extra-contractual coverage.   1.87    1.15
1 .  how and when to prepare accurate, timely           2.60    1.04
     cost/benefit analyses for payor.
14.  methods to determine cost-effectiveness.           2.75    0.97
3.   coverage, exclusions, and conditions of an         2.42    1.14
     insurance policy.
4.   extended medical payments.                         1.96    1.04
6.   medical reserves.                                  2.11    1.10
20.  how to evaluate necessary medical services for     2.93    0.98
     cost containment purposes.
12.  techniques used in service negotiations.           2.39    1.12
8.   eligibility criteria for funding sources in the    2.60    1.02
     private sector.

Psychosocial Aspects of Disability (Alpha=.90)          2.82    0.65

31.  principles of relationship building.               2.81    0.98
29.  theories of personality.                           2.66    0.94
56.  the interaction of psychological and social
      factors                                           3.03    0.84
     as they pertain to wellness and independence.
30.  principles of group dynamics.                      2.30    1.01
55.  the interaction of biological and social factors
      as                                                2.87    0.90
     they pertain to wellness and independence.
28.  theories of family functioning.                    2.69    0.89
54.  the principles of self-determination and           2.86    0.92
     empowerment.
81.  psychological characteristics of wellness.         2.97    0.84
80.  psychological characteristics of illness.
72.  the characteristics of functional and
      dysfunctional                                     2.90    0.87
     coping and their implications for health care.

Table 2 Training Needs of Rehabilitation Counselors In Health Care Settings

Knowledge Domain     Importance  Preparedness  Discrepancy   t-value
                        M (SD       M-(SD)
Medical Treatment     2.81 (.68)   2.16 (.90)      .65       24.5(*)
 Modalities &
 Services
Community Resources   2.34 (.72)   1.95 (.75)      .39       15.8(*)
 and Services
Rehabilitation Case   3.30 (.49)   2.74 (.77)      .56       22.4(*)
 Management
Cost Containment      2.43 (.73)   1.45 (.95)      .97       31.2(*)
 Psychosocial
 Aspects              2.82 (.65)   2.75 (.73)      .07        ns.
  of Disability

(*) p [less than] .0001

Factor 1: Medical Treatment Modalities and Services. There were 20 knowledge items contained within this factor, which refer mostly to levels of care in acute and chronic phases, benefits of alternate care, the disease process and the range of treatment modalities and services, pharmacological management, and principles of health care maintenance. The alpha coefficient computed for the total sample was .95 and the average interitem correlation was .47, indicating high internal consistency of the items constituting this factor. The mean perceived importance rating for this factor was 2.81 and the mean reported preparedness rating was 2.16. It should be noted that although rehabilitation counselors felt this knowledge area was moderate to highly important, their overall preparedness in this area was at a much lower level.

Factor 2: Community Resources and Services. This factor was comprised of 23 knowledge items. The majority of these items related to public and private funding sources and availability of community-based health care, independent living, and rehabilitation services. The alpha coefficient computed for the total sample was .95 and the average interitem correlation was .45, indicating high internal consistency of the items constituting this factor. The mean perceived importance rating for this factor was moderate, 2.34, and the mean reported preparedness rating was also moderate, 1.95.

Factor 3: Judgement and Problem-solving. There were 19 knowledge items contained within this factor, which refer to such items as confidentiality, service plan development, and clinical problem-solving skills. The alpha coefficient was computed to be .92 and the average interitem correlation was .39. The mean perceived importance rating for this factor was 3.30 and the mean reported preparedness rating was 2.74. This factor was considered the most important knowledge area for case management practice, but the respondents believe that they are only moderately well prepared in this knowledge area.

Factor 4: Cost Containment. There were 11 items which clearly represent working knowledge related to health care cost containment issues. The alpha coefficient was computed to be .89 and the average interitem correlation was .42. The mean perceived importance rating for this factor was 2.43 (moderately important) and the mean reported preparedness rating was 1.45 (little preparation). Apparently, cost containment knowledge was perceived by rehabilitation counselors as moderately important. However, they acknowledged that they are least prepared in this area of case management practice.

Factor 5: Psychosocial Aspects of Disability. There were 10 knowledge items comprising this factor. The majority of these items related to biopsychosocial factors related to chronic illness and disability and intervention techniques. The alpha coefficient was computed to be .90 and the average interitem correlation was .47. The mean perceived importance rating for this factor was 2.82 (the second most important knowledge area according to the participants) and the mean reported preparedness rating was 2.75. This knowledge factor was considered close to highly important and the respondents believe that they are quite well prepared in this knowledge area.

Perceived Knowledge Importance and Reported Preparedness

As stated above, respondents reported notable discrepancies between the importance of various factors, and the degree to which they felt well prepared in those areas. Three of the identified actors (Medical Treatment Modalities and Services, Professional Judgement and Problem-Solving, and Psychosocial Aspects of Disability) were considered highly important or close to highly important by the counselors in this study. The participants reported less than optimal preparation in three knowledge domains: Medical Treatment Modalities and Services, Community Resources and Services, and Cost Containment. Additionally, for every factor, respondents' degree of preparedness was reported to be at least somewhat weaker, relative to the importance ascribed to the five knowledge domains.

The researchers utilized the CCMQ to determine whether there are significant differences in perceived importance and reported preparedness in case management knowledge areas according to employment settings. As mentioned, the majority of the rehabilitation counselors in this study are employed by independent case management companies and insurance rehabilitation firms, constituting 74.9% of the sample. A multivariate analysis procedure, the Hotelling's [T.sup.2] for independent samples, was used as an omnibus test to compare these two groups of rehabilitation counselors' perception about the importance of case management knowledge across the five empirically derived CCMQ factors. Factor-based subscale scores were used. For calculation purposes, the summed item scores were divided by the number of items within each factor-based subscale. A series of univariate t-tests was also performed. The level of significance was divided by five for each pair-wise comparison to control for Type I error ( = 01/5 = .002). The results indicated no significant difference between the two groups across the five CCMO importance factors, [T.sup.2] =.006, F(5,834)=1.016, n.s. Similarly, no significant difference was found between the two groups across the five CCMQ preparedness factors, [T.sup.2] =.009, E(5,795)=1.506, n.s. Evidently, knowledge importance and perceived preparedness for effective case management practice were not influenced by the respondents' employment settings.

Discussion

Summary

Analyses of the rehabilitation counselors' responses to the CCMQ reveal five relatively stable knowledge factors: Medical Treatment Modalities and Services; Community Resources and Services; Professional Judgement and Problem-Solving; Cost Containment; and Psychosocial Aspects of Disability. While rehabilitation counselors generally appear to be well prepared to meet the demands of case management practice, it would appear that a knowledge deficit in several critical areas may inhibit this groups' ability to perform specific functions at an optimal level. These results suggest direct implications for pre-service and continuing education in the preparation of rehabilitation counselors for case management roles within disability/health care settings.

Implications

Recent developments in health care reform and managed care have had a major impact on rehabilitation counselors who work in health care or related programs such as those of medical rehabilitation, mental health, psychosocial rehabilitation, geriatric, and viral infectious diseases (Lui, 1993). For example, Strickland (1995) predicted that the small, stand-alone companies that used to dominate the private rehabilitation field are in danger of obsolescence because of intense competition and the pressure to provide more for less in today's highly competitive managed care environment. As a result, small rehabilitation companies are increasingly being acquired by the new players in the managed care arena, including managed care organizations, health care workers' compensation insurance carriers, hospital management companies, home health agencies, and HMOs. The shift of practice focus from vocational rehabilitation to integrated case management/managed care services predicted by Strickland (1995) has most certainly begun to take place (Beckley, 1995; Murer, 1996). Rehabilitation counselors who are hired by these health care companies as case managers will have to perform both medical and vocational case management functions. As a result, rehabilitation counselors in managed care settings now need to be knowledgeable about clinical practice guidelines and procedures, treatment patterns, disease management, and cost analysis and cost containment procedures (Choppa et al., 1996).

The value of vocational rehabilitation in the workers' compensation arena has been under close scrutiny in recent years (Berkowitz & Berkowitz, 1991). Many states have curtailed the vocational rehabilitation benefit in their workers' compensation law based on enormous expenditures for vocational rehabilitation services with little perceived positive claim outcomes (Habeck, Kress, Scully, & Kirchner, 1994). As a result, there is a trend towards the increased use of medical case management services for early intervention and a reduction in the use of vocational rehabilitation services (Habeck et al., 1994). Managed care techniques are also increasingly being recognized as a viable alternative to the workers' compensation system through the coordination of medical care to maximize a rapid return to work and prevent the development of long-term disability (Clifton, 1996). Lui (1993) contended that the managed care approach to workers' compensation will immensely alter the traditional role of each medical and rehabilitation professional, and totally change the delivery of medical and vocational rehabilitation services typically provided to industrially injured workers. Rehabilitation counselors who work in workers' compensation managed care programs will perform an expansive array of new functions, often requiring increased medical case management and including such cost containment functions as utilization review, bill auditing, lost time analysis, lost work day analysis, and cost analysis.

Our study confirmed the practice shift of rehabilitation counselors in the health care and workers' compensation environments. Participants in our study clearly suggested that they have to be more knowledgeable about medical treatment modalities and services. Unfortunately, it appears that many rehabilitation counselors feel somewhat inadequate in this increasingly important area. These findings are consistent with the observation of Choppa et. al. (1996) who noted that

The area in which [vocational rehabilitation

counselors] are sometimes weak is the medical ... the

vocational counselor's knowledge of these issues may

be somewhat basic or superficial or may be confined

to conditions that are commonly seen in workers'

compensation claims that result in lost time from

work ... Because vocational rehabilitation has not

been a heavily regulated profession until very

recently, some vocational case managers may come

from backgrounds where they were not required to

take many (or any) medical courses. These

individuals need to carefully assess their strengths

and weaknesses and identify ways of improving

their expertise through continuing education and

volunteer work (pp. 48-49).

It also appears that rehabilitation counselor case managers are increasingly required to deal with cost containment issues. The need to develop increased expertise in cost containment is made even more challenging by the paradigm shifts that have accompanied the move toward managed care (Gerson, 1995). Traditional cost containment strategies may be less effective or even antithetical to cost-effective care in a capitated environment (Birmingham, 1996). Consequently, rehabilitation counselors are challenged to acquire cost-containment skills that are effective in a rapidly changing health care and reimbursement system.

Rehabilitation counselor case managers in this study also felt a strong need to be knowledgeable about community-based services and the resources required for community re-entry, including health care services, independent living services, and vocational services. At the same time, they indicated that they are not very well prepared in these areas. The reported lack of preparation in this area is somewhat surprising, as the ability to access community resources and services has long been considered to be an important function of rehabilitation counselors and is typically addressed in rehabilitation counselor education programs. It may be that the case managers' perceived lack of preparation in this area is related to an increased difficulty in accessing funding for needed services, as traditional payors have begun to "tighten the belt."

There is little doubt that rehabilitation counselors who seek employment in health care settings will increasingly be required to demonstrate the knowledge, skills, and abilities to perform both medical and vocational case management functions. Lui (1993) projected that 24-hour medical coverage and team approaches in managing health-care patients or industrially injured workers will be the norm in the 21st century. If his projection is accurate, rehabilitation counselors should profit from expanding employment opportunities as case managers in managed care programs. Concurrent with the trend toward growing opportunities in managed care case management, it is likely that employment opportunities in public rehabilitation will level off, and opportunities in traditional private sector rehabilitation will decline. It is imperative for rehabilitation counselor educators to re-evaluate their training curriculums to help prepare practicing as well as aspiring rehabilitation counselors to practice effectively in today's highly competitive managed care environment. Additional research is also needed to explore how to better utilize the two major groups of case management practitioners (i.e., rehabilitation counselors and nurses) within the disease/disability management process. As Burgess (1996) notes, however, the combined efforts of all case managers from all disciplines will be needed over the next several years as our health care system continues to transform itself. Nurses and rehabilitation counselors alike will be challenged to acquire new skills and blend their areas of relative strength. As Burgess (1996) concludes, "Case management will evolve over the next decade and will be driven by multiple factors, the least of which will be based in individual disciplines... No one will have to relearn how to conduct clinical care. Rather, each will be called upon to raise her/his level of practice" (p. 12).

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