Survey of rehabilitation counselor education programs regarding health care case management in the private sector.

For the past several years, the health care and insurance industries in America have been undergoing significant reform in order to rein in the high cost of delivering health care services. Managed care has become a cornerstone of this process (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 (Owens, 1996). According to Mullahy (1995a), the number of case managers has risen astronomically in recent years. These individuals come from diverse professional backgrounds and practice settings that include nursing, rehabilitation counseling, and social work.

Case management, however, is not a new concept. Many human service, rehabilitation, and health care professions have a history of using case management models in the execution of their responsibilities. For example, in many psychiatric rehabilitation work settings social workers are frequently hired as case managers to coordinate the provision of community-based services to their clientele (Sledge, Astrachan, Thompson, Rakfeldt, & Leaf, 1995). Case management is also an extremely important function of rehabilitation counselors in both public and private sectors (Leahy, Chan, Taylor, Wood & Downey, 1997; Leahy, Szymanski & Linkowski, 1993; Matkin, 1995). Similarly, medical case management is increasingly being viewed as an essential aspect of professional nursing practice (Lamb, 1995).

The Development of Private Sector Case Management

The impetus for case management practice in health care settings can be traced to the skyrocketing cost of workers compensation in the 1970s. Private sector rehabilitation grew in response to the demand for vocational rehabilitation services by workers' compensation insurance carriers (Matkin, 1995). Federal legislation also promoted the growth of private sector case management services. albeit inadvertently. The Rehabilitation Act of 1973 gave priority within the state-federal vocational rehabilitation system to individuals with severe disabilities, causing workers' compensation carriers to seek vocational rehabilitation services for their (typically less severely injured) claimants in the private sector Habeck, Leahy, Hunt, Chan & Welch, 1991). In increasing numbers. rehabilitation nurses and rehabilitation counselors were hired to provide both medical and vocational case management services to workers' compensation claimants.

In the late 1980s, case management began to develop its own impetus as an independent profession (E. Holt, personal communication, December 1, 1996). In 1991, 29 organizations involved in the field gathered in Dallas, Texas, at a consensus meeting organized by the Individual Case Management Association. The intent was to agree upon the philosophical basis for case management, a universal definition of case management, and a set of meaningful practice standards. Eventually, a certification program for case managers was developed, including eligibility criteria and content areas for a certification examination. On July 1, 1995, the Commission for Case Manager Certification (CCMC) was incorporated as a separate, independent credentialing body. Although the process is still very young, there are already over 19,000 Certified Case Mangers (CCMs) who have completed certification requirements.

With technical and administrative support from the Foundation for Rehabilitation Education and Research, Leahy (1994) surveyed 14,078 practicing case managers representing multiple professional disciplines in a variety of work settings. His research suggested that case managers share a common knowledge base required for case management practice comprised of five factors: 1) coordination and delivery of services; 2) physical and psychosocial aspects of disability; 3) benefit systems and cost benefit analysis; 4) case management concepts; and 5) principles of community re-entry.

Roles and Functions Studies

In 1991, Matkin used a job analysis approach to identify work role categories as well as knowledge requirements associated with the major tasks performed by rehabilitation specialists in the private sector (Matkin, 1995). Seven major knowledge domains were identified, but case management and the coordination of rehabilitation services were determined to occupy approximately 40% of the subjects' work time.

More recently, Leahy, Chan, Taylor, Wood, and Downey (1997) identified seven empirically derived knowledge factors as important for effective private rehabilitation practice. These knowledge factors are: vocational assessment and planning; case management and reporting; expert witness testimony; employment and disability related legislation and regulations; community resources; psychosocial and functional aspects of disability; and job analysis and modification. In their study, knowledge of case management was rated as most important with a mean (M) score of 3.24 (based on a five-point Likert-type scale, with 0 meaning not important to 4 indicating absolutely essential). Their study may reflect a shift in private rehabilitation practice from predominantly vocational counseling and job placement to medical and vocational case management. These same researchers also found several distinctions between private rehabilitation practitioners with a rehabilitation counseling background and those with a nursing background. While specialists with rehabilitation counseling expertise viewed knowledge in vocational rehabilitation as important to private rehabilitation practice, practitioners with a nursing background believed that community resources and medical rehabilitation service coordination activities were more important.

Current trends in health care are causing these distinctions to become increasingly bluffed, however. The spiraling costs of workers' compensation which began in the late 70s reached crisis proportions by the 1990s, causing states to look for novel costcontrolling approaches (Cerne, 1994). In many states, vocational benefits were reduced or eliminated. Because many managed care strategies had begun to show positive results in lowering costs within the group health arena, their reach now extended into the workers' compensation system (Daiker, 1995; Lui, 1993; Tabak, 1995). By the mid-1990s, rehabilitation counselors employed as workers' compensation case managers found that referrals had dwindled and/or that the services requested were much more limited in scope. Case managers who may once have dealt solely in workers' compensation had to diversify into other "product lines". Most recently, the trend in health care has been toward integrated delivery systems, wherein multiple insurance lines, levels of care, and populations are being integrated into one system of care (Aron, 1996).

Strickland (1995) predicted that rehabilitation and case management companies would increasingly be procured by managed care organizations, health and workers' compensation insurance carriers, hospital management companies, and home health agencies. This is proving to be accurate (Beckley, 1995; Smith, 1996). Consequently, case managers are being employed to manage the care of patients with chronic illnesses and disabilities throughout their recovery process, from initial medical treatment to return to work (Fowler & Stokes, 1996; Kreider, 1996). The dramatic emergence of the CCM credential and a related professional organization (i.e., Case Management Society of America [CMSA]); the drift of managed care into workers' compensation; the concurrent shift of workers' compensation case managers into other case management arenas; and the trend toward integration of health care delivery systems have resulted in a shift in both the roles of rehabilitation counselors and the information and skill areas required to fulfill them (Choppa, Shafer, Reid, & Siefker, 1996; Mullahy, 1995b; Owens, 1996).

Rehabilitation Counselor Education

The monumental growth of private sector rehabilitation counseling that occurred during the 1980s caused concern that rehabilitation counselor case managers were not receiving an educational preparation adequate for this new role. Consequently, Matkin and Riggar (1986) conducted two national surveys to evaluate the effects of the growth of private sector rehabilitation employment on graduate-level RCE programs. Results indicated that RCE programs had begun to offer some additional course work focused on private sector issues. However, a majority of rehabilitation counselors indicated that they felt the RCE curricula did not adequately prepare graduates for private sector work, particularly in the areas of medical aspects of disability, job placement, case management, legal and ethical issues, disability compensation insurance systems, and vocational evaluation.

There has been little attention given to the degree to which RCE programs have adjusted to meet these needs, and still less on the extent to which RCE programs are currently modifying curricula to meet the educational needs of rehabilitation counselor case managers to reflect role changes resulting from current health care system trends. The purpose of this study is to survey RCE programs accredited by the Council on Rehabilitation Education (CORE) regarding their educational practices and their views of various aspects of case management as it exists in the private sector.

Method

Instrument

The Survey of Graduate Programs in Rehabilitation Counseling Regarding Case Management was adapted from the CMSA Survey of Graduate Programs in Nursing (Haw, 1996). The original CMSA instrument was developed to survey graduate programs in nursing regarding course work, curricular content, faculty expertise, and clinical learning experiences in case management. The modified version consists of 17 items designed to gauge the awareness and intentions of RCE faculty regarding:

* recent trends in employment growth for case managers;

* the nature and extent of case management content in RCE curricula;

* the potential of establishing a special track in case management; and

* the potential for collaborative curriculum revision efforts with school of nursing.

Case management is considered a primary role and function for rehabilitation counselors in both public and private sector settings. For this reason, the following definition was provided at the outset of the survey which clearly established the intent to examine private sector case management:

Case Management is defined as a process, generally

occurring within the private sector, of assessing, planning,

coordinating, monitoring and evaluating medical and

return-to-work services to achieve optimal outcomes in the

most cost-effective manner possible.

Participants

The Survey of Graduate Programs in Rehabilitation Counseling Regarding Case Management was sent to the coordinators/directors of all 85 Core-accredited, master's level RCE programs in October, 1996. A total of 51 usable returns were received by the December 1996 due date, resulting in a response rate of 60%. Of the 51 programs responding, 43 (84%) were located in public universities and eight (16%) were in private institutions. Responding programs had an average of 3.65 core, faculty (SD = 1.75; range of 2 to 12) and an average enrollment of 39.4 students (SD = 19.5; range of 14 to 100). Sixteen respondents (31%) also had doctoral programs in rehabilitation with an average student enrollment of 9.67 (D = 5.18; range of 1 to 20), but the survey questions were specific to the master's degree level of education.

Results

Case Management Training, Employment, and Research Resources

Thirty-nine respondents (76%) indicated that they were moderately to very well aware of employment trends in case management. Thirty-one programs (61%) responded that they have little or no difficulty finding literature and other educational materials on case management. Similarly, no difficulty finding opportunities for clinical training in case management was experienced by 37 respondents (72%). However, 29 programs (57%) reported moderate to a great deal of difficulty in finding good case management role models for their students. Research in the area of case management appears minimal, with only seven programs (14%) reporting some to a great deal of scholarly activity.

In terms of faculty preparedness to support case management training, responding RCE programs averaged 1.43 faculty members with graduate-level preparation in case management (SD = 1.88) and a similar number (M = 1.49; D=1.30) with direct case management job experience. Fewer faculty had supervisory/management experience in case management (M = 1.10; D = 1.42). Far more faculty possessed rehabilitation counseling job experience which included case management responsibilities (M = 2.43; SD = 1.50). Mindful that the average number of faculty members per program is only 3.65, it is reasonable to conclude that case management expertise is adequately if not well represented among RCE faculty, at least in the context of rehabilitation counseling activity. In terms of the Certified Case Management (CCM) credential, however, the majority of programs (39; 76%) reported that they have no CCM faculty member. Seven programs counted one CCM (14%), and five programs reported two CCMs (10%) among their faculty.

Curricula Addressing Case Management Content Areas

Respondents were asked which of 47 case management content areas were currently addressed in their curricula. Table 1 summarizes these findings.

Table 1.

Case Management Content Areas Addressed by RCE Curricula

ADDRESSED BY 90-100% OF RESPONDING RCE PROGRAMS Vocational Assessment Job analysis Job modification and restructuring Job placement Assistive technology Government-funded payment systems (e.g., SSDII, SSI, Medicaid, Medicare)

ADDRESSED BY 80-89.99% OF RESPONDING RCE PROGRAMS Ethical issues in case management Consultation to employers Community resource utilization Case management process Case management roles and functions Coordinating client services Definition, philosophy, and principles of case management

ADDRESSED BY 70-79.99% OF RESPONDING RCE PROGRAMS Relevant state and federal laws and regulations Developing transitional work programs Development of individualized case management plans Models of case management Current trends in case management

ADDRESSED BY 60-69.99% OF RESPONDING RCE PROGRAMS Monitoring and evaluating client outcomes Professional liability Legal issues in case management Interdisciplinary collaboration Documentation and reporting requirements Implementing case management plans Expert witness testimony Private insurance payment systems (e.g., group health, workers compensation, LTD) Case management tools Disability management

ADDRESSED BY 50-59.99% OF RESPONDING RCE PROGRAMS Time management Interacting with attorneys, adjusters, employers, and other stakeholders Case management professional literature and research

ADDRESSED BY 40-49.99% OF RESPONDING RCE PROGRAMS Managed care concepts and terminology Life care planning Pain management principles History of case management

ADDRESSED BY 30-39.99% OF RESPONDING RCE PROGRAMS Utilization review/management Identifying and aligning expectations of multiple stakeholders Ergonomic principles and practices Total quality management Loss of earning capacity evaluation Levels of care

ADDRESSED BY 10-29.99% OF RESPONDING RCE PROGRAMS Case management credentialing Case management software Case management professional associations Policy and contract limits Cost containment strategies Medical reserves

Using an outcome approach, respondents were asked to indicate those clinical competencies related to case management that graduates of their programs are expected to possess. The results are reported in Table 2.

Table 2 Case Management Clinical Competency Expected Upon Completion of RCE Program

Clinical Competency Expected                   %
Upon Graduation                          Responding Yes

Client referral to community resources         98
Comprehensive client assessment                90
Monitoring client progress                     84
Management of client case load                 82
Evaluation of client outcome                   75
Implementation of case management plan         75
Case management planning                       75
Monitoring of services                         69
Collaboration with health team                 69

Methods of Case Management Education

Of the 51 RCE programs responding to the survey, none have an entire degree program or major devoted to case management. Thirteen programs (25%) indicated that they have more than one course devoted to case management M=2.55 courses). For example, the University of Wisconsin-Milwaukee has five required courses and three elective courses available; Drake University has four required and two elective courses; California State University at San Bernardino and the University of Tennessee both have three required courses. Nineteen programs (37%) have one required course and two (4%) have one optional course. But the overwhelming majority of programs (40 total; 78% -- including those just mentioned) indicated that they implement case management training across the curriculum. Eight respondents (16%) reported that they require clinical learning experience in case management. An additional 13 programs (25%) indicated that they have optional clinical learning experiences.

Plans for Curriculum Revision and Enhancement Just over half (26; 51 %) of all respondents indicated either a moderate or great deal of interest in establishing a specialization track in case management to better prepare students for employment in case management positions. Another 18 programs (35%) suggested some interest existed. Seven respondents (15%) reported no such interest. Again, over half of all programs (27; 54%) indicated a willingness to develop such a specialization in collaboration with a school of nursing. Within this group, 24 programs (89%) supported co-taught courses on such topics as principles of case management, disability management, medical case management, or collaboration within health care teams/systems. Nineteen respondents (70%) supported joint clinical supervision, and 18 programs (67%) endorsed concepts of shared resources. A large minority of respondents (23; 45%) either had no interest in a collaboration with nursing programs or no opportunity due to the lack of nursing education on campus.

Comparison of Findings to Haw (1996) Survey of Nursing Schools

Many of the design considerations for the present study were replicated from a survey conducted by Haw (I 996) that was intended to: 1) capture current educational practice in case management at both the graduate and under-graduate of nursing education; 2) identify difficulties faculty may experience in case management education; and 3) determine the educational background, work experience, and research involvement of faculty in case management.

The findings of the two studies are compared in the context of several limitations. In the Haw (1996) study, data collection occurred one year earlier; the professional role of faculty respondents was different; the response rate was lower; the representation of private universities was higher; and the percentage of accredited programs that responded was slightly lower. More important, the nursing school respondents were not provided with a definition of case management, thus the perception of the term may differ somewhat for each group. Nonetheless, in order to provide a preliminary comparison regarding the experience of the two professions in their approach to pre-service case management education, the following key findings are offered:

* Only 20% of graduate and 4% of undergraduate nursing programs had one or more case management courses available. The figure for RCE programs is 66%.

* However, 89% of graduate and 95% of undergraduate nursing programs included content on case management in required courses. Content beyond a basic level was much more likely in graduate programs. This same figure for graduate RCE programs is 78%.

* Clinical case management experiences were required for 24% of graduate and 12% of undergraduate nursing programs, compared to 16% of RCE programs. Clinical experiences were optional for 38% of graduate and 22% of undergraduate nursing programs, compared to 26% of RCE programs.

* Performance expectations for graduates of graduate nursing programs averaged 67% across the nine basic case management functions. The same figure for undergraduates was 42%. The figure for RCE graduates was 80% (see Table 2). Haw (1996) observes a peculiarity in that the strength of case management education in nursing appears to reside in graduate programs, yet the baccalaureate degree is often indicated as a requirement for practice in case management job listings.

* Both nursing and RCE programs had similar experiences with respect to the ready availability of educational materials (70% vs. 61%) and the difficulty of finding good role models (67% vs. 57%). Difficulty finding good clinical placements appeared more problematic for nursing programs (55% vs. 28.5%).

* Generally speaking, nursing faculty have similarly high levels of case management education themselves, although it appears less intensive than for RCE program faculty (e.g., self-study or continuing education vs. graduate course work). RCE faculty appear to have more case management work experience. Scholarly activity in the case management arena is similarly low for both groups of faculty.

Discussion

Case management has been solidly established as a primary role and function for rehabilitation counselors for many years. Recently, however, case management has been elevated to the level of a major area of practice and, indeed, is regarded by some as a freestanding profession shared by various allied health and human service professionals. On balance, RCE faculty appear to be aware of these trends. They have prepared themselves adequately in terms of traditional case management experience. They do impart case management content in their curricula, and they expect students to be reasonably proficient in all core case management competencies upon graduation.

Yet these results also suggest that many RCE programs offer little opportunity for students to access valid information and experience in regard to evolving case management paradigms. Only 41% of respondents offer clinical experiences in private sector case management (mostly optional). Whereas all CORE-accredited programs have Certified Rehabilitation Counselors (CRCs) on faculty, only 23% have one or more CCMS. Over half of the respondents expressed difficulty finding case manager role models and do not impart such seminal information as managed care concepts, life care planning, ergonomics, or utilization review. For at least some RCE programs, although a conceptual foundation regarding case management in rehabilitation counseling is present among faculty, this knowledge is not being imparted.

In some RCE programs, private sector exposure has been deliberately limited due largely to the influence of public funding and the influence of state-federal vocational rehabilitation programs in predominantly state universities. In spite of the fact that significant disabilities such as mental illness and brain injury are treated largely in the private sector today, some educators hold to the view that services to severely disabled persons are rendered only in the public sector. This viewpoint appears outdated, given the increasing infusion of private sector principles into all functions of government e.g., welfare reform), the outsourcing of government services to the private sector (e.g., corrections), and the reality that more than one third of all CRCS practice in the private sector.

The failure of RCE programs to impart these critically important skill and knowledge areas is a matter of grave concern to some. For example, Leahy, Chan, Shaw, and Lui (1997) found that, while rehabilitation counseling case managers consider skills in cost containment to be a critical part of their jobs, they felt somewhat ill prepared in this area. Perhaps RCE faculty members themselves are experiencing difficulty in remaining current with the rapid developments in health care and case management. Although about one-third of RCE faculty have been employed as case managers, the climate surrounding the job of a case manager in the early 1980s is significantly different than today's environment which includes practice standards, capitation, and integrated health care systems. Indeed, most of those case management content areas that receive minimal exposure by RCE programs have emerged as critically important activities only within the past few years. For example, a review of Table 1 reveals that those content areas addressed by the majority of RCE programs tend to represent "traditional" Core-accreditation requirements (e.g., vocational assessment, job placement, coordination of services, and plan development). Those content areas that are relatively neglected, however, have emerged only recently as important developments in the field (e.g., case management credentialing, utilization review/management, cost containment, and case management software).

Clearly, some RCE programs are eager to enhance case management content as a way of insuring the relevance and vitality of their curricula in the years ahead. About one-fourth of all respondents appear to be moving aggressively to revise their curriculum and provide comprehensive and effective case management training on a par with the emphasis given to counseling. They seek to maximize access by their students to the opportunity structure which is available to them today and tomorrow, just as they expect students to do for their clients. To support this goal, RCE faculty clearly have a great deal of case management expertise. Although dispersed across an ambitious curriculum, two-thirds of all key case management concepts are being conveyed in some manner to students of over half of the responding RCE programs.

Other educators feel that the current nature and scope of case management training is more than adequate. They maintain that the infusion of case management content across their curriculum, especially in the supervision of practica and internships, is appropriate. They further maintain that the definition of case management used in this survey is not specific to private sector endeavors, but is generic to the professional practice of rehabilitation counseling across most, if not all, settings. Others argue that there is currently a tragic overemphasis on credentialing, and that the CRC represents the best single credential for the practicing rehabilitation counselor and includes all of the necessary skills (including case management) to practice effectively in a variety of settings. Many faculty already have multiple certifications and licenses beyond the CRC, and each has associated fees and continuing education requirements, making the maintenance of these credentials both challenging and expensive. Finally, they argue that the solid representation of CRCS in the private sector is ample evidence that current approaches to professional preparation are adequate.

These data do not tell us which position is misguided. It is clear that case management services to individuals with disabilities are increasingly being provided within integrated systems in which managed care concepts, medical information, and cost containment skills are considered paramount. Complacency on the part of RCE faculty whose programs emphasize only those skills associated with traditional vocational case management may place graduates at a decided disadvantage in the marketplace. Choppa et. al. (1996) notes that the blending of workers' compensation and managed care systems has created a need for rehabilitation counselors to increase their knowledge in such areas as negotiating rates, medical management, and understanding managed care reimbursement systems:

Because of the ... many components and skills in case

management and the overlapping nature of vocational and

medical issues in many lines of insurance, especially workers'

compensation, it is no longer possible to separate medical

from ... vocational case management (p. 50).

In any event, it is clear that Core-accredited programs are uniform neither in terms of the value they place upon case management training nor in their approach for addressing the issue. Nonetheless, for those who are open to curriculum modifications irrespective of CORE requirements or the preferences of funding sources, the following suggestions are offered:

1. Review the current curriculum with an eye toward each of the case management content areas and clinical competencies identified in this study. Seek ways in which such material can be updated, better organized, and systematically delivered under the auspices of current course offerings, required and elective.

2. Restructure existing courses to maximize case management training. For example, the traditional triad of "disabilities" courses might be re-configured as Case Management in Rehabilitation: Medical Aspects, Psychosocial Aspects, and Vocational Aspects. In addition to studying pertinent disabilities, a collateral goal would involve the intensive study of how medical, mental health, and vocational case managers function in public and private settings under a variety of funding mechanisms.

3. Design new courses devoted exclusively to case management principles and practices.

4. Encourage faculty to become active in CMSA, the National Association of Rehabilitation Professionals in the Private Sector (NARPPS) and/or the National Association of Service Providers in Private Rehabilitation (NASPRR), and to become or remain current in case management practice through the continuing education opportunities afforded by these organizations.

5. Using alumni and state organizations of CMSA, NARPPS, and NASPRR, identify high quality clinical training opportunities that emphasize ethical case management activity.

6. Provide meaningful representation by such supervisors on the Community Advisory Board of the RCE program.

7. Develop strategic partnerships on and off campus with training programs and professional organizations from nursing, social work, allied health disciplines, and health care administration. A comparison of this survey's findings with the Haw (1996) results suggest that RCE programs and schools of nursing have a great deal in common with respect to curricular development in the case management arena. Explore the prospects for collaborative training opportunities in both the classroom and community.

8. Recruit undergraduate students from nursing, social work, and allied health majors because they have an excellent basis upon which to build case management competencies at the graduate level. Eliminate deficiency courses and broaden the recruitment basis beyond those who major in human services, as most educational backgrounds have reasonable relevance to modern rehabilitation endeavors.

9. Review library holdings for high quality publications addressing case management such as The Journal of Care Management, The Journal of Case Management, and others.

10. Consider case management issues including relevant training as fertile grounds for further rehabilitation research.

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