Across the health care spectrum, the drive to improve cost-effectiveness, safety, and quality in care delivery continues. This is congruent with the growth in value-based and accountable care models, in which health care organizations, physicians, and other providers are reimbursed on the basis of outcomes achieved, compared with the cost of delivering those outcomes (NEJM Catalyst, 2017). As the emphasis on value in care delivery increases, there is an even greater need for health care organizations to mitigate financial and reimbursement risks, such as to adhere to Medicare's Hospital Readmissions Reduction Program and value-based reimbursement methods (Centers for Medicare & Medicaid Services, 2019). Value, however, speaks to more than just cost reductions. Pursuit of the "triple aim" (and more recently, the quadruple aim) in health care continues to be an imperative: to improve the experience of care, achieve better health of individuals and populations, and reduce the per capita cost of care, while ensuring clinicians' engagement and satisfaction (Institute of Healthcare Improvement, 2019). At the center of these demands and expectations is the professional case manager.

The 2014 role and function study (results of which were published in late 2015 and early 2016) observed that the demands encompassed by the triple aim translated to greater expectations for and emphasis on outcomes, efficiency, cost-effectiveness, and safe delivery of health and human services, while also underscoring the importance of patient-centered care, care coordination, care/case management, ethical and legal practice, and care transitions (Tahan, Watson, & Sminkey, 2015). Now, 5 years later, the role of the professional case manager is further highlighted, particularly in the context of value-based care models. In addition, as health care organizations seek to become accredited, there is a benefit to employing professional case managers, particularly those who demonstrate their competency by achieving nationally recognized credentials such as the Certified Case Manager (CCM) credential. For example, within accountable care organizations and patient-centered medical or health homes, greater emphasis has been placed on interdisciplinary teams working together to achieve desirable outcomes for safe, quality, cost-effective, and affordable care. The professional case manager, as a key member of such interprofessional teams, has been shown to be uniquely prepared to impact the experience of both the patient and the health care organization. Furthermore, as the 2014 role and function study determined, the case manager is often responsible for monitoring, measuring, and evaluating the outcomes achieved by teams composed of physicians (and other providers), nurses, and other clinicians against specific goals. Examples of these goals are reducing utilization of scarce and costly resources and improving safety and quality of care (Tahan et al., 2015). The 2019 role and function study, as explained in detail herein, further affirmed the importance of evaluating and measuring quality and outcomes, while adhering to legal, ethical, and nationally recognized practice standards.

Like each of the national practice surveys conducted by the Commission for Case Manager Certification (CCMC) in 1994, 1999, 2004, 2009, and 2014, the latest (2019) survey illustrated how the current and continuously evolving demands placed on professional case managers underscore the importance of credentials: educational background, certification, and experience. As case managers demonstrate their competence in essential activities and key knowledge areas for practice, they provide assurance to the various health care stakeholders, especially consumers (i.e., patients or clients), that they are well qualified for their roles. To avoid misinterpretation, activities in the context of the role and function study are the day-to-day tasks or interventions case managers engage in when providing care for patients who may be known as "clients" or "residents" in some practice settings. The knowledge areas refer to what case managers must know and the skills they must demonstrate to competently and effectively perform these day-to-day tasks.

One widely accepted way to demonstrate competency is through national certification. A key component of the certification process is the development of the certification examination itself, ensuring that it is meaningful, evidence-based, and substantiated by and relevant to current practice. This process requires a rigorous, scientifically valid national field research study, which is also referred to as a practice analysis or role and function study. The CCMC conducts the role and function study on a regular and ongoing basis (every 5 years) to ensure that the CCM certification examination process and content remain relevant within the constant evolution of the practice in the ever-transforming health care environment.

The CCMC was established in 1992, making it the first and largest nationally accredited organization that certifies professional case managers today. Ensuring that the CCM examination is empirically based allows the CCMC to maintain its accreditation by the National Commission for Certifying Agencies. The CCMC's 25-year history of conducting national role and function studies and the rigor of its certification process are of vital importance to professional case managers and other practitioners in health and human services. Most important, however, are safeguarding the public interest and protecting the consumers of case management services. In this regard, the scientific research forms the basis of the integrity of the certification examination and assures the public that persons holding the CCM have demonstrated advanced knowledge and competence in areas most essential to current case management practice. With the backing of a scientific, evidence-based national study, the CCM credential is increasingly recognized in the field, including as a condition of employment for many case managers. In the latest (2019) role and function survey, approximately 40% of survey respondents reported that their employers require certification-a percentage that has held roughly steady from the previous role and function study.

This article is the first of a two-part series on the 2019 national role and function study. The first part details the importance of such a study to the field of professional case management, the conduct and scientific rigor of the practice analysis by surveying a few thousand practicing case managers, and the evaluation of the relevance of essential activities and knowledge domains compared with current practice. What emerges is a detailed picture of the current state of case management practice; this includes the typical practice of a case manager, years of experience, professional background, work setting, and more. Part II, to be published in the July/August 2020 issue of this journal, will examine the findings of the role and function study as an evidence base to inform the structure and design of the CCM certification examination.

The Role and Function Study/Practice Analysis

The objectives and process of the role and function study have been well documented over the years (Tahan & Campagna, 2010; Tahan, Downey, & Huber, 2006; Tahan, Huber, & Downey, 2006; Tahan et al., 2015). As with prior role and function studies, the 2019 study used the practice analysis survey method to describe case management practice and delineate the roles and functions of professional case managers and the related and necessary knowledge areas for practice. This method ensures that procedures are in place to obtain descriptive information about micro tasks performed by case managers and the important individual and minute knowledge topics and skills needed to adequately perform those tasks (Tahan, Downey, et al., 2006).

The conceptual perspective on the case manager's role and function study has its roots in the classic role theory of Thomas and Biddle (1966). A profession consists of a system of roles that are socially defined and structurally interdependent. Similarly, the professional case manager exhibits behaviors (i.e., tasks) in the social context of providing health and human services to clients and their support systems, in partnership with other health and support service providers, in a specific level of care or across multiple settings. The case manager and these other individuals impact each other's contribution to the total care provision for a client as each brings his or her own specialized knowledge (professional background discipline), skills, functions, tasks, competencies, and role responsibilities, based on the position or title each holds in this social structure of care provision. Considering that the term "role" is highly abstract and refers to a set of expected behaviors exercised in a social structure (i.e., the health care delivery environment) and applying specific knowledge areas, it is the norm in role and function studies that the practice analysis is conducted at the micro level of these behaviors and knowledge topics; therefore, the detailed descriptions of the individual activities and knowledge areas of the case manager's role are shared in the two-part article. Roles, functions, activities, and knowledge occur in a hierarchical order where role is the most abstract and a single activity or area of knowledge is the most concrete (see Table 1).

TABLE 1 Differentiating Role, Function, Activity, and Knowledge

The practice analysis study design involves a multimethod approach consisting of individual and group meetings with subject matter experts, survey instrument development, and data collection from a large number of practicing professional case managers using the role and function survey instrument developed for the purpose of this national study (Tahan et al., 2015). As in prior years, the current study addressed the following three main research questions:

1. What are the essential activities/domains of practice of professional case managers?

2. What are the knowledge areas necessary for effective case management practice?

3. Is there a need to revise the blueprint of the CCM certification examination? And if so, what modifications are warranted?

This first article in the two-part series addresses research Questions 1 and 2, whereas the second part will focus on answering research Question 3 in addition to other key conclusions that impact the continued evolution of the case management practice.

In early January 2019, CCMC representatives and the Prometric staff, who were engaged to support the conduct of the role and function study, held a project planning meeting. During this meeting, they agreed on the study purpose and discussed the selection of members for the Subject Matter Experts Task Force and the Test Specifications Committee. They also agreed on meeting dates, logistics, timelines, and procedures of the survey delivery for data collection and analyses. A representative group of 14 subject matter experts from the professional case management community served on the Subject Matter Experts Task Force and another 12 individuals served on the Test Specifications Committee. Some of the experts functioned on both forums to ensure continuity of the work while seeking the perspectives of new/additional experts who were not involved in the initial task force and the survey instrument design. This mix of experts is a best practice in job analysis studies. Appointments to each of these groups ensured that these subject matter experts represented the various regions within the United States, as well as diverse practice settings of case management, professional disciplines, and educational backgrounds of case managers, and different types of client populations served by case managers. Such diversity was essential to ensure the development of a current, relevant, and practice-based role and function survey instrument.

The Subject Matter Experts Task Force held a 2-day meeting in March 2019 to develop the role and function survey instrument, which was later used for data collection for this national study. Activities conducted during the meeting included a review and, as needed, revision of the major domains, individual tasks within each activity domain, and individual knowledge topics within each knowledge domain. The task force members determined what was necessary for inclusion in the survey instrument based on expected competent performance of professional case managers in a variety of settings and professional disciplines. An expert in professional case management practice and a scientist on the roles and functions of case managers, the primary author of this article, in collaboration with the Prometric staff, facilitated the 2-day meeting. This expert ensured the open sharing of, and dialogue about, the varied viewpoints of the participants regarding the domains and individual items included in the survey. The subject matter experts brought their tacit knowledge, experiences, and backgrounds in the practice of professional case management into these discussions and ultimately the conclusions made. Building consensus on final recommendations was a main objective of this forum, resulting in accurate delineation of simple, clear, concise, and duplication-free items on the survey instrument and within each of the activity and knowledge domains.

The expert and scientist who facilitated the 2-day meeting had developed a draft survey instrument from which the subject matter experts could begin their work. The draft survey instrument was based on previous instruments used by the CCMC in prior role and function studies, expert opinion, and a select review of recent relevant literature. The scientist and task force members agreed to maintain the six activity and five knowledge domains from the 2014 role and function study; however, updated details of the items and associated structure within each of these domains reflected current practice of professional case management.

The task force members also discussed, and revised as warranted, the survey rating scales and demographic (i.e., background and general information) questions. Following the meeting, the Prometric staff constructed the draft online survey, which covered the six tasks/essential activity domains and five knowledge domains (as listed later in this article).

After refinements were incorporated, as appropriate, the survey instrument was prepared for a pilot test using a secure online data collection platform. Eighteen professional case managers, also from diverse practice settings and professional health disciplines, participated in the pilot test of the survey instrument. These professionals had no previous involvement in the development of the instrument. They reviewed it for relevance, completeness, clarity, and currency and offered suggestions for improvement as they deemed necessary. On the basis of this review, the survey was then revised and finalized. The pilot test participants found the instrument highly relevant and complete and offered minimal nonsubstantive suggestions. Thereafter, the subject matter experts reviewed the suggestions and finalized the survey instrument to consist of 247 items, inclusive of demographics and background (see Table 2).

TABLE 2 Role and Function Survey Instrument Composition

The 2019 Case Manager's Role and Function Study Instrument

As with the CCMC's past survey instruments, the final case manager role and function survey instrument used in the 2019 study contained five sections, described as follows. The instrument comprised theoretical domains, applying those that were used in the 2014 survey.

* Section 1-Background and demographic questions (19 items): Survey participants were asked to provide general background information pertaining to each participant individually, including primary job title, percentage of time spent in providing direct case management services to patients/clients, primary workplace setting, number of years performing professional case management work, professional background/discipline, whether the participant is certified as a CCM, practice location (geography) in the United States, highest academic education degree achieved, age, gender, and ethnicity. None of these questions were mandatory, allowing participants to skip any questions they did not feel comfortable answering.

* Section 2-Essential activities (138 items): The activity statements were organized across six theoretical domains as described in Table 2, with each item starting with an action verb.

Survey participants were asked to rate each of the essential activity statements using two rating scales that focused on importance and frequency. First, for importance, they responded to the question, "How important is performance of this task/activity in your current position?" using a 5-point rating scale (rating of 0 = of no importance, 1 = of little importance, 2 = moderately important, 3 = important, and 4 = very important). Then, for frequency, they responded to the second question, "On average, how frequently do you perform this task/activity in your current position?" referring them to consider answering based on an average day of work and using a 5-point rating scale (0 = never, 1 = seldom, 2 = occasionally, 3 = often, and 4 = very often).

* Section 3-Knowledge areas (90 items): The knowledge and skill domains were organized across five domains, also as described in Table 2. Items within each of these domains differed from those of essential activities by starting with a noun compared with an action verb.

The knowledge statements, like the essential activity statements, were also rated using two scales: one for importance and one for frequency. For importance, survey participants were asked to answer the question, "How important is this knowledge to performance of your job responsibilities in your current position?" using a 5-point scale (0 = of no importance, 1 = of little importance, 2 = moderately important, 3 = important, and 4 = very important). As for frequency, they were asked to answer the question, "On average, how frequently do you use this knowledge in your current position?" also referring them to consider answering based on an average day of work and using a 5-point scale (0 = never, 1 = seldom, 2 = occasionally, 3 = often, and 4 = very often).

* Section 4-Domain comprehensiveness and test content recommendations: After survey participants rated each of the essential activities and knowledge statements for a specific content (domain) area, they rated the adequacy and comprehensiveness of the content, using a 5-point scale (0 = very poorly, 1 = poorly, 2 = adequately, 3 = well, and 4 = very well). Participants were also asked whether any of the essential activities or knowledge statements were missing and, if so, to submit additional essential activities or knowledge statements using a designated free-text area on the survey.

For each of the five knowledge domains, participants were asked to suggest, in their opinion, how many test questions should be included in each of the domains on the CCM certification examination. Participants answered on the basis of a scenario of 100 questions to make it easier for them to determine the amount per domain. Because certification examinations test knowledge rather than tasks and activities, participants were restricted to answer this section for the knowledge domains only.

* Section 5-Other comments: Survey participants were provided the opportunity to comment on the following questions: "How do you expect your work role to change over the next 5 years? What tasks will be performed, and what knowledge will be needed to meet changing practice demands?" These questions were optional and provided the participants the opportunity to share any thoughts as they desired.

The research team disseminated the role and function survey instrument via an e-mail invitation with an open survey link to almost 60,000 professional case managers directly or indirectly involved in care provision to clients and their support system. This purposive, nonrandomized sample of potential participants consisted of both board-certified and not-yet-certified case managers. The survey invitation with the open link was also posted on the CCMC's website and shared on CCMC social media forums including LinkedIn. Two continuing education credits were offered for completing the survey. Data collection commenced in June 2019 for a period of 3 weeks. After reminder e-mails, the submission deadline was extended for another week for a total of 4 weeks. The e-mail invitation to participate in the study and the introductory page of the survey instrument communicated adherence to ethical conduct of research involving human subjects. It also assured prospective participants of the following: (a) voluntary completion and submission of the survey; (b) that it was anonymous and did not require sharing of any personal or identifiable information; (c) privacy and confidentiality of data collection, analysis, and storage procedures; and (d) that final reports would only reflect the findings in the aggregate form.

Data Analysis

As with prior surveys, researchers took steps to ensure anonymity, confidentiality, and privacy of the study participants. They segmented the analysis into sections (e.g., demographics, activity or knowledge items, and subgroups based on practice settings or professional disciplines). They then computed descriptive statistics for the demographic survey questions and in analyzing responses to each essential activity and knowledge statement, inclusive of mean importance and frequency ratings (Tahan et al., 2015). The researchers also reviewed the demographic questions and determined which comparative subgroup analyses were appropriate for examining significant similarities or differences between subgroups, specifically on importance and frequency ratings of essential activity and knowledge statements.

Because some of the demographic questions, such as job title and work setting, included an "other" option, the research team reviewed all the "other" responses to reclassify them, where appropriate, to one of the formed subgroups. Despite this activity, not every "other" response was attributable to a subgroup and therefore some remained unclassified. The proposed subgroups were then reviewed for appropriateness with CCMC representatives who also were experts in the case management field. This activity of data management was necessary because survey participants reported more than 35 different job titles and 30 work settings; this activity addressed not only feasibility of analyses for such a large number of subgroups but also availability of enough participants in each subgroup to contribute to appropriate conclusions. Combining job titles and work settings based on perceived similarities and the opinion of the expert researcher (and other subject matter experts) resulted in a manageable number of relevant subgroups for meaningful analyses. This subgrouping activity resulted in 11 groups based on job titles and another 11 based on work settings. For example, one subgroup consisted of case management educators within a case management program whether in an academic or practice setting. In addition, the subgroups created on the basis of the participant's communicated location (state) of practice consisted of the nationally recognized "nine regions" within the United States as opposed to an analysis of subgroups based on each state of practice. This led to the reduction of the subgroups for manageable comparative analysis and examination of differences based on geographic location.

Researchers applied the index of agreement (IOA) test statistic to examine the degree of the similarities (or differences) that existed among the subgroups relevant to their perception of importance and frequency ratings on essential activities and knowledge areas.

Role and Function Study Results

Characteristics of the Study Sample

Although 5,416 participants responded to the survey during the 4 weeks of data collection, 2,606 responses were excluded because they did not meet the 55% survey completion requirement for inclusion in the study. The remaining 2,810 survey responses were included in the final study sample. Although the current study sample is considered a large national sample appropriate for practice analysis studies, the researchers noted that the number of eligible responses in the 2019 survey was lower than that in prior surveys: 4,165 in 2004, 6,909 in 2009, and 7,668 in 2014. However, on the basis of the analysis of the survey responses and the sizes of the subgroups created, it was determined that a representative group of individuals engaged in case management completed the 2019 survey in sufficient numbers to meet requirements for conducting meaningful statistical analysis. This was evidenced by review of the responses for each of the background and general information questions, as well as confirmation by the Test Specifications Committee.

Answers to the background and demographic questions (see Table 3) revealed that nearly half of respondents (47.24%) were care/case managers, 9.58% were managers/supervisors, 5.44% were care/case coordinators, and 4.85% were director of case management/care management/care coordination. Other titles reported included utilization reviewer/manager (4.88%), social worker (4.59%), consultant (2.18%), staff/clinical nurse (1.55%), case management educator (1.29%), quality management specialist (1.29%), and rehabilitation counselor/vocational evaluator/disability specialist (0.70%).

TABLE 3 Background and Demographics (Total Sample = 2,810)

The most common primary work/practice settings were health plan/insurance company/reinsurance (29.36%) and hospital/acute care/hospital system (22.14%), a trend that was consistent with the 2014 role and function study. Workers' compensation insurer/agency was the setting for 8.89% of respondents, followed by independent/private case or care management company (6.18%), ambulatory/outpatient care/primary care/urgent care clinic (5.41%), and government agency (2.67%). The array of case management practice settings may be more evidence of a value-based care approach across health and human services, which emphasizes the role of the professional case manager in mitigating financial risks and improving quality and outcomes. Generally, the distribution of the 2019 study sample by practice setting was similar to that of the 2014 study.

Also consistent with the 2014 role and function study, nearly half of survey respondents (46.48%) said their organizations do not require case managers to work on weekends compared with 49.10% in 2014. Among the remainder, 40% said they were required to work on weekends whereas 13.52% were to work on-call-only on weekends compared with 37.44% and 13.46%, respectively, in 2014. However, by combining the number of those working on weekends with those on call, the conclusion (consistent with 2014 survey results) is that case management practice is no longer a 5-day operation for more than half of respondents.

Half of survey respondents (50.48%) reported that their organizations do not have case managers who work on legal holidays in contrast to 53.05% in 2014, whereas one third of respondents (33.3%) were required to work on holidays compared with 27.07% in 2014 and 16.22% were to work on-call-only for holidays compared with 19.87% in 2014. These results seemed consistent with 2014 survey findings and confirm a continued rising trend compared with 2009 study findings (Tahan et al., 2015). As with the requirement to work on weekends, this further supports the trend that case management practice has been expanding beyond the traditional 5-day operation.

More than half of respondents (56.69%) performed case management work for 11 years or more compared with 58.07% in 2014. Specifically, 16.38% reported working 11-15 years in the field, followed by 15.79% working 16-20 years, 12.46% working 21-25 years, and 12.06% working 26 years or more. In addition, 23.22% reported working 6-10 years in the field and 16.05% have been in the field for 3-5 years. With nearly 44% in the field for 10 years or less, compared with nearly 42% in 2014, and a little over 20% involved for 5 years or less, compared with 19% in 2014, it appears that ongoing efforts to address workforce readiness must continue to take hold to proactively ensure that qualified candidates are available to fill an ongoing and growing number of professional case management positions. Although we have seen a slight and slow increase of those in the field for 10 years or less, additional growth is necessary to curtail professional management workforce challenges. To meet this growing demand, professional organizations and associations directly or indirectly involved in case management practice need to continue their efforts to address the aging workforce and succession in the case management field. Innovative strategies in workforce planning and management designed by both employers and professional associations must be implemented to overcome workforce readiness concerns.

Roughly consistent with 5 years ago, 39% of respondents in the 2019 survey said that certification in case management is required to practice at their organizations/facilities compared with 40.36% in 2014 (Tahan et al., 2015). This steady rate shows a solid base for recognition of case management certification by employers and a gain from 35.9% of employers in the 2009 study. In addition, nearly one third of survey respondents (31%) reported that there is an additional monetary reward/compensation offered for certification in case management, which is roughly consistent with the 30% of respondents in the 2014 survey, and 26.7% in 2009. Over the years, more employers have come to recognize the value of board-certified case managers, for their positive impact on the quality and safety of care and on the economics of health care.

Consistent with the prior role and function study findings, the most commonly reported professional background for case managers is nursing. Although far in the majority, nurses account for a smaller percentage: 82.23% in the 2019 survey compared with 88.78% in 2004. As evidence of the case management field is becoming increasingly professionally diverse, 11.17% of survey respondents identified themselves as social workers, nearly double the percentage in 2014 (5.84%). Other professional backgrounds reported in the 2019 survey include vocational rehabilitation/disability management (1.56%) and licensed professional clinical counselor, licensed professional counselor, psychologist (1.26%), compared with 0.63% and 1.13%, respectively, in 2014. The vast majority of respondents in the 2019 survey (97%) held the CCM credential, whereas 3% did not. Of those who reported being CCM credentialed, nearly half (44.56%) have been credentialed for less than 5 years compared with 32.47% in 2014. This finding reflects the success of outreach to increase awareness of case management and the importance of certification. Of the remainder, 23.42% have been credentialed for 5-10 years, 12.06% for 11-15 years, 11.12% for 16-20 years, and 8.84% for 21 years or more. Asked to identify all the other credentials currently held by participants other than the CCM, 25.96% reported registered nurse-board certified, 3.11% certified rehabilitation registered nurse, and 2.4% licensed graduate social worker. In addition, 36% held no other certifications other than CCM and 64% held multiple certifications including the CCM credential.

As for educational background of the study participants, 80.62% held a bachelor's degree or higher (46.79% bachelor's degree, 32.24% master's degree, and 1.59% doctoral degree), a nearly 10-percentage point gain from 2014. In addition, 14.55% held an associate degree (down from 20.7% in 2014) and 4.84% a nursing diploma (down from 9% in 2014). The increase in advanced degrees reflects a higher bar of qualifications for those serving in professional case management roles today. This increase may be slightly attributed to the noted rise in the number of social workers who participated in this survey and who usually hold a bachelor's degree or higher. In addition, because nursing has continued to be the dominant professional discipline for case managers at 82.23% in this study, the increase in the advanced academic preparation of case managers may be reflective of the direct result of nursing's focus on achieving 80% of baccalaureate-prepared nursing workforce by 2020 as part of the Institute of Medicine's recommendations on the Future of Nursing Report published in 2010.

More than half of survey respondents (54.31%) were between 51 and 65 years of age compared with 61.24% in 2014, with the largest group being 56-60 years of age (21.04%, compared with 24.69% in 2014). Another 16.71% were between 61 and 65 years of age and 16.56% were between 51 and 55 years of age, compared with 14.33% and 22.22%, respectively, in 2014. In addition, 13.75% reported being between 46 and 50 years of age (13.74% in 2014) and another 9.17% between 41 and 45 years of age (10.27% in 2014). Those who were 40 years and younger accounted for 15.9% compared with 10.04% in 2014, which is a hopeful sign of younger professionals being attracted to the field. Nonetheless, with nearly 45% older than 55 years, it raises a concern about the need for workforce succession planning in the field. Case management is not an entry-level role; rather, it is a specialty or advanced practice almost always requiring prior experience in one's background professional discipline before transitioning to the role of professional case manager. Those who become case managers have had a number of years in prior roles, such as nursing, social work, or vocational rehabilitation. Consistent with prior studies, respondents reported that case management is largely learned on the job (43.45% of respondents), with another 9.91% describing their training as self-directed/self-taught. However, one third of respondents (33.62%) reported learning via conferences and seminars, plus on-the-job training, indicating a growing number of offerings to help support the professional development of case managers today in diverse ways other than on-the-job training. In addition, 5.84% reported learning based on an academic degree or certificate-granting formal educational programs. Despite the increase from 3.14% in 2014, this rise in preparation based on academic programs continues to be insufficient to address workforce challenges.

Like the findings of the 2014 study, the vast majority (94.82%) reported their gender as female, and 80% were White (non-Hispanic). Other ethnicities reported were also consistent with the 2014 findings, including 8.27% Black or African American, 3.73% Asian, 3.40% Hispanic or Latino, 1.44% two or more ethnicities, 0.44% American Indian or Alaska Native, 0.18% Hawaiian or other Pacific Islander, and 2.51% preferred not to answer. Geographically, the largest percentage (22.66%) of study participants practiced in South Atlantic region of Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, and West Virginia. In addition, the East North Central region (Illinois, Indiana, Michigan, Ohio, and Wisconsin) accounted for 17.68% and the Mid-Atlantic (New Jersey, New York, and Pennsylvania) came in at 13.97%, whereas the West South Central and Pacific regions came at 10.64% and 10.15% respectively.

Essential Activities and Knowledge Areas

The data analyses consisted primarily of descriptive statistics: mean, frequencies, and standard deviations. Results reported by CCMs and non-CCMs were combined because of the small sample of non-CCMs (82 participants) and the strength of agreement between the two groups in terms of their ratings of activities and knowledge statements. The strength of agreement about the practice of case management among these two subgroups was measured using the IOA, which showed an IOA of 0.95 for tasks/activities and 0.89 for knowledge. These were considered high agreements being greater than the 0.80 cutoff point for acceptability; this also meant that the two groups agreed in their perception of case management practice (tasks, behaviors, or activities) 95% of the time and 89% of the time on the application of the knowledge for practice. The descriptive statics and test of agreement among the various subgroups created on the basis of the demographic variables assisted in answering the research Questions 1 and 2: "What are the essential activities/domains of practice of professional case managers?" and "What are the knowledge areas necessary for effective case management practice?" The results were consistent with findings from the data analyses of descriptive statistics in prior years (Tahan & Campagna, 2010; Tahan et al., 2015). As with the 2004, 2009, and 2014 role and function studies, the most recent (2019) study applied criterion for interpreting the mean importance ratings based on the 5-point rating scale. This criterion would ensure that only validated essential activities and knowledge statements were used to answer the three research questions described earlier. The cut point value for accepting or rejecting a statement was set at the 2.50 mean importance rating, which is the midpoint between moderately important and important (Tahan, Huber, et al., 2006). This criterion was also consistent with the CCMC's past role and function studies. Findings from data analyses performed for the frequency of executing such activities and application of the knowledge topics were used to inform the interpretation of the results where the importance ratings were borderline/slightly lower than what is considered acceptable (i.e., <2.50 but >2.39).

Among the essential activities (see Table 4), all 61 statements within "delivering case management services" domain showed an importance rating of 2.5 of higher, as were all 14 statements of "accessing financial and community resources" and all 13 statements of "adhering to ethical, legal, and practice standards" domains. Within the "managing utilization of health care services" domain, 20 out of 21 statements received the requisite 2.5 mean importance rating value, as did 14 out of 16 statements in the "evaluating and measuring quality and outcomes" domain. However, and as was seen in the past role and function studies, results were mixed for the items comprising the "delivering rehabilitation services" domain, with only six out of 13 statements achieving a 2.5 or higher mean importance rating, whereas one statement was "borderline" (2.40-2.49) and six failed (<2.40). As noted in previous role and function analyses (Tahan et al., 2015), the reason may be that professional case managers do not typically spend much of their time on vocational and rehabilitation activities and such care may be necessary only for a small percentage of the client population served by these case managers. In addition, only 1.56% of survey respondents reported having a rehabilitation-related professional background and only 2.15% reported working in a rehabilitation facility. Experts would agree that professional case managers must be able to perform basic/general activities of rehabilitation such as identifying a client's need for rehabilitation services, whether medical or vocational in nature, and making the appropriate referral for in-depth assessment of needs and delivery of such services for these clients. In contrast, the specialized involvement in the comprehensive performance of the tasks/activities comprising the "delivering rehabilitation services" domain might be the role responsibility of case managers practicing in such care settings and with specialized client populations (i.e., medical and/or vocational rehabilitation).

TABLE 4 Essential Activities-Mean, Standard Deviation, Importance, and Frequency Ratings

Among the knowledge domains (see Table 5), 34 out of 37 statements in the "care delivery and reimbursement methods" domain were given an importance rating of 2.5 or greater, with three statements at "borderline" (2.40-2.49). All 23 of the statements in the "psychosocial concepts and support systems" domain were rated 2.5, as were nine out of nine statements in the "ethical, legal, and practice standards" domain. In the "quality and outcomes evaluation and measurements" domain, 10 out of 11 statements were rated at 2.50, whereas one statement failed (with a mean of <2.40). Consistent with the findings in vocational and rehabilitation essential activities and tasks domain-and as found in prior role and function surveys (Tahan et al., 2015)-only four out of 10 knowledge statements passed with a rating of 2.5 or greater whereas six failed. The four statements that passed were related to "adaptive technologies, functional capacity evaluation, rehabilitation posthospitalization or acute health condition, and rehabilitation concepts." These recognize the importance of the case manager's general knowledge in identifying the client's need for specialized rehabilitation services and acting upon securing these services as part of the client's case management plan of care.

TABLE 5 Knowledge Areas-Mean, Standard Deviation, Importance, and Frequency Ratings

Analysis of Findings by Participant Subgroups

The researchers analyzed the role and functions study data to determine how similar or different the perceptions of the various participants were relevant to their importance ratings of the essential activities and knowledge areas, using the IOA test statistic. The IOA statistic provided a method of computing the similarity in judgments between groups. In this study, it measured the extent to which subgroups agreed in their perceptions of the importance of tasks or knowledge topics (Tahan, Huber, & Downey, 2006) to the practice of professional case management. The IOA statistic is more tailored to the purpose of a practice analysis than the correlation coefficient. Although the correlation coefficient measures the relationship between the full range of possible ratings, the IOA focuses on whether two groups agree that the content should (or should not) be included in a certification examination. As one of the major purposes of this practice analysis is to identify appropriate certification examination content, the IOA has provided a statistical method to address this question at the subgroup level. Furthermore, the IOA requires a smaller sample size per group whereas the correlation coefficient requires a larger sample size to provide a reliable measure of agreement.

As with prior analyses, if the subgroups' mean importance ratings of an item were above the critical importance value (>=2.50), there would be a resulting natural agreement that the content of the item was important for case managers. In contrast, if the subgroup ratings of an item were below the critical level (<2.50), then the subgroups would be found to be in agreement that the content of the item was considered less important or unimportant, depending on how low the mean importance rating score was. Any differences in mean importance ratings among subgroups indicated that potentially there was disagreement as to whether the content was important.

The IOA scores ranged from 0 to 1, with 1 representing perfect agreement and 0 denoting full disagreement. The researchers applied the same criteria for analyzing the IOA as was described in the 2014 CCMC's role and function study of case managers (Tahan et al., 2015). The criteria were as follows:

* IOA of 1.00 = perfect agreement

* IOA >=0.80 and <=1 = high agreement

* IOA <0.80 and >=0.70 = moderate agreement

* IOA <0.70 = Disagreement

Table 6 presents the findings of the IOA analyses of the various subgroups computed on the basis of the demographic and background questions and on the mean importance and frequency ratings of their respective activity statements. Details for the IOAs computed for the knowledge domains and across the various subgroups will be shared in Part II of this article series. The results ranged as follows:

TABLE 6 Index of Agreement in Essential Activities Among Various Subgroups

* Job title: 0.05-0.95 for activities and 0.52-0.96 for knowledge

* Percentage of time in direct case management: 0.50-1.00 for activities and 0.74-0.99 for knowledge

* Work/practice setting: 0.77-0.99 for activities and 0.70-0.98 for knowledge

* Years of experience in case management: 0.93-0.99 for activities and 0.87-0.98 for knowledge

* Primary method of learning case management practice: 0.86-0.99 for both activities and knowledge

* Holding the CCM certification in case management: 0.95 for activities and 0.89 for knowledge, whereas IOAs for the employer's requirement of certification were 0.96 for activities and 0.91 for knowledge

* Number of daily hours worked: 0.90-0.98 for activities and 0.88-0.96 for knowledge

* Primary professional background/disciplines: 0.68-0.93 for activities and 0.66-0.90 for knowledge

* Region of case management practice: 0.95-1.00 for activities and 0.92-0.99 for knowledge

* Academic degree background: 0.93-0.99 for activities and 0.88-0.98 for knowledge

* Age: 0.93-0.99 for activities and 0.88-0.99 for knowledge

* Gender: 0.96 for activities and 0.93 for knowledge

* Ethnicity: 0.93-1.00 for activities and 0.90-1.00 for knowledge

The IOAs for the essential activity domains computed for the primary job title subgroups were lowest for respondents with the quality specialist and utilization reviewer/manager titles. One may attribute this observation to quality specialists not providing direct case management services to clients whereas the utilization review/managers may perhaps focus more on the financial and reimbursement aspects of care rather than actual direct care provision of health and human services. The IOAs for the percentage of time spent in direct case management services to clients showed a uniformly high agreement among all the subgroups except for those who indicated having no (0%) direct contact with clients. It is not a surprise that this subgroup disagreed with all the others, knowing that the participants in this subgroup are functioning in roles that do not comprise direct interaction with clients and therefore may not have the opportunity to exercise full case management role responsibilities. As for the primary work setting subgroups, the skilled nursing/long-term care facilities subgroup demonstrated modest disagreement with the government-based subgroup (IOA = 0.79), independent/private case management subgroup (IOA = 0.78), and workers' compensation subgroup (IOA = 0.77). The IOAs for the remaining work settings showed agreement of 0.80 or more. Years of practicing case management subgroups demonstrated high agreement across the board.

The IOAs for the essential activity domains for the case management certification requirement by employers of professional case managers demonstrated near perfect agreement; similarly, the IOAs of the CCM and non-CCM subgroups showed high agreement irrespective of whether certification was required. Such high agreement also extended to monetary reward for case management certification, regardless of whether the employer offered any monetary compensation. Considering the analyses for subgroups based on daily work schedule (daily hours of work/operations), there was nearly perfect agreement as well among all ranges of work hours. These findings demonstrated that the practice of professional case management did not vary on the basis of the presence of certification or the number of work hours, as long as the case manager maintained direct contact with the client in care provision. The IOAs for the subgroups based on primary professional background/discipline demonstrated high agreement among the nursing, social work, and counseling subgroups compared with the occupational therapy and vocational rehabilitation counseling subgroups that observed low to moderate agreement (IOAs = 0.68-0.75). Comparative analyses based on whether the participants held the CCM credential and the number of years since becoming certified showed high agreement on the essential activity domain ratings irrespective of the year the CCM credential was acquired. As for the primary method to learn case management, subgroup analyses resulted in IOAs reflective of high agreement across the subgroups regardless of the method applied in learning case management practice. Similarly, the IOAs for the subgroups based on states, territories, or regions of practice, age, gender, ethnicity, and academic degrees demonstrated high agreement among the various subgroups, therefore demonstrating that the practice of the case manager is consistent regardless of these demographic variables.

Comprehensiveness of the Case Manager Role and Function Study Instrument

Researchers asked the study participants to indicate at the end of each of the essential activity and knowledge domain sections of the survey instrument how well the statements reflected important case management practice in the domain's specific focus area. Participants used a 5-point rating scale (1 = poorly representative, 2 = fairly representative, 3 = adequately representative, 4 = well representative, and 5 = very well representative). For each essential activity or knowledge domain, the participants rated the content as "adequately," "well," or "very well" in covering the essential activity or knowledge domain areas. This indicated the domains were comprehensive in content and appropriately reflected the current practice of professional case management. These favorable results also mean that the survey instrument's construct and content were comprehensive enough and therefore appropriate to describe the case manager's role and function from the perspective of those currently in actual practice.

After rating the content coverage of each essential activity or knowledge domain, the survey participants had the opportunity to write in (free text) any essential activity or knowledge statements that they believed were missing from the delineation. Upon review of these responses by the researchers, it was found that the study participants used the comments opportunity to share real-life examples and anecdotes from their daily involvement in case management practice. Such comments further supported the comprehensiveness of the survey instrument used in this study.

Conclusion

The case manager role and function study is helpful in profiling the professional case manager. The results describe the case manager as someone who holds the title care/case manager (47.24% of respondents), is White (80%), female (94.82%), is between 51 and 65 years of age (54.31%), spends more than 70% of her time providing direct case management services to clients and their support systems (46.02%), and works in either a health insurance plan or a hospital/acute care/hospital system settings (51.5%). She has been working as a case manager for more than 10 years (56.69%), is a registered nurse (82.23%), holds a bachelor's degree or higher (80.62%), and works mostly 8 hr per day (65.77%). In addition, this case manager learned her professional role on the job or by being self-redirected/self-taught (53.36%) and practices in either the South Atlantic or East North Central region of the United States (40.34%).

Understanding the state of professional case management practice through the perceptions of those directly or indirectly involved is necessary for ongoing enhancement of this practice. Regularly completed, rigorous research-based examinations of the roles and functions of case managers are also important for charting the evolution of such role(s) and determining how best to prepare the next generation of case managers to manage the workforce challenges being experienced today. The case management professionals described in this role and function study may be known by varied titles; yet, a commonality and growing trend is greater visibility and higher expectations that they can contribute to value creation across health and human services and care settings-demonstrated through quality and safety outcomes and cost-conscious service provision that minimizes the health provider's financial risks. With these demands, case managers must possess the requisite knowledge and competency in essential activities that constitute the key role responsibilities. The 2019 role and function study has identified and evaluated these requirements through a rigorous, scientifically based, large national survey and practice analysis. Other research findings, as will be discussed in Part II of this article series, are also used to inform the content and composition of the CCM certification examination, based on the 2019 survey and analysis-one of the main research questions addressed in this study.

Part II will be published in the July/August 2020 issue of Professional Case Management.

Acknowledgments

The authors thank the many individuals who provided invaluable assistance throughout the conduct of the CCMC Role and Function Study to update the examination of the CCM credential, especially the more than 2,800 individuals who participated in different phases of the practice analysis, including the Subject Matter Experts Task Force and Test Specification Committee members, Survey Pilot Test participants, and survey respondents. The authors give special thanks to Debby Formica, CAE, Vivian Campagna, MSN, RN-BC, CCM, and Martine DiDonato at the CCMC, and the Prometric team for providing guidance and coordination throughout this study.

References