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 …