The Basics

CM 7 is designed to insure that only people that meet the case manager qualifications outlined in CM 5 are doing the clinical aspects of case management.  The standard accomplishes this by fixing responsibility for the management of each case squarely with the case manager, including supervision of any duties performed by persons who are not case managers.  The organization must clearly define the non-case manager's role, and the case manager must oversee the performance of the non-case manager to assure he/she stays within that role.

A non-case manager might assist with the case management process through such activities as collection of non-clinical data, finding resources (e.g., tracking down a DME provider), handling satisfaction surveys, and general administrative help.  The key is to keep non-case managers away from clinical assessment and decision-making.

Management Tips

What is particularly important is that the P&Ps (and training on those P&Ps) make it absolutely clear that non-clinical support staff are not involved in the collection of clinical data, even if structured.  That is clearly the job of the case manager in the assessment process, which must be evident in your documentation. 

The kinds of functions non-clinical support staff may perform include:

• Outbound administrative calls (e.g., requesting a copy of the medical record,  scheduling)
• Faxing, mailing, emailing education materials identified by the case manager
• Scheduling delivery durable medical equipment that the case manager has approved
• Facilitating claims adjudication

URAC Accreditation Tips

The three elements of this standard each are weighted 4.

The documents you'll want to submit on AccreditNet for desktop review include job descriptions of case managers (including their supervisory role described here) and the non-case managers (making sure they don't have any clinical responsibilities), as well as a P&P describing this oversight process and, perhaps, scripts to help the non-case managers, when interacting with consumers, steer clear of clinical issues.

Compliance with this standard during the onsite review will be assessed through interviews of both case managers and non-case managers alike.

Of course, not all case management programs have non-case managers involved in the process.  For this, I recommend a P&P or attestation from a senior manager that makes it clear that this is the case and that the standard, therefore, is not applicable.