In honor of National Case Management Week, which takes place October 9^th – 15^th, we are featuring a stellar Nurse On the Move, Ann Marie Marks RN, BSN, CCM. Marks has over 36 years of nursing experience. She started in the critical care field and eventually segued into case management at a time when this field was being developed.

Marks helped pave the way for the role of the case manager, including creating content for the first Certified Case Manager (CCM) exam in 1990. She’s helped define what case management entails and continues to serve as an advocate for patients by coordinating care across a large, interdisciplinary health care system.

Today, she serves as an RN case manager consultant and speaker; she presents at the Thomas Jefferson College of Health Population Health Academy, and was the #1 ranked speaker at NAHQ’s 2016 National Quality Summit. She recently served as the Director of Care Coordination at the Delaware Valley Accountable Care Organization where she continues to consult on post-acute services.  She was previously Director of Commercial Case Management for Humana, Inc., in Louisville, Ky., and as the National Director of Integrated Care Management for Aetna’s Medicaid division. In 1999, Marks was appointed by the governor of Kentucky to serve as Deputy Secretary of Health, with oversight of Commonwealth’s Primary Care Case Management Program (KenPAC), and programs within the Department of Medicaid Services, CCSHCN, and Office of Aging.

I was fortunate enough to sit down with Marks in our Philadelphia office to discuss what case management is, what it was, and how it’s evolved, including why it’s so important in today’s world of health care.

Read on to discover the vital role that case managers play and for more case management news:

• Subscribe to Professional Case Management , the Official journal of the Case Management Society of America (CMSA).  Marks is a CMSA member and a long-time subscriber to the journal and says, “Over the years, this journal has been the source for evidenced-based studies and peer-reviewed literature for case management. It’s the most often cited and is often a source of reading materials for classes on case management. For me, this journal is one of my go-to spots when I’m attesting to the value of case management or saying a program hasn’t proved valuable.”

 

• Check out these books on case management from Wolters Kluwer.

 CMSA Core Curriculum for Case Management, COLLABORATE® for Professional Case Management, Case Management














The interview:

Q: You’ve been a registered nurse for nearly 40 years and specialized in critical care. What made you decide to become a nurse?
A: When I was 15 my father was in a horrible auto accident. He was taken to a larger city hospital about 70 miles from our small town.  His jaw was wired and he had a chest tube, a feeding tube, and many injuries.  He could not be left alone, and my mother needed to return to her position as a teacher.  Somehow I was nominated to “stay” with him. I slept on a cot in his room and within a day the nurses and doctors started teaching me to care for him. I learned so well that they allowed me to take him home three weeks earlier than anticipated! Three years later, I was awarded a college scholarship to a college that had a Bachelor's in Nursing and knew I wanted that. But having the experience of living in a hospital for eight weeks and caring for a complex patient, my dad, certainly influenced my choice to be a nurse. It was the confidence those nurses instilled in a teenage girl.

Q: How did you enter into the case management field?
A: It seemed like years before what I did was called case management. When I entered in the early 1980’s, we were referred to as rehabilitation nurses.  It was my encounter of a “rehab nurse” when I was working in ICU that inspired me to explore the field. A nurse arrived in our hospital to discuss a patient who had been in a catastrophic industrial accident. She was very business-like and wore a suit! I found it intriguing that she was a nurse, not providing direct medical care (treatments, medications, etc.,) but was coordinating the care. I came to learn that she was working for a company that provided services to large self-insured employers and insurance carriers. Eventually, I was able to get my foot in the door there. The president, Mary Gambosh, hired me part-time, and challenged me with expanding her business in Kentucky.

But more importantly she trained me about the principles of good case management, and shared everything she knew. Mary assigned me to a large account in the coal fields of eastern Kentucky. That was the beginning of a great career in case management and the expansion of nursing for me and a mentorship under one of the legends in this field, Mary Gambosh, RN.

Q: Can you define what a case manager is and speak to why the name, “case manager,” has changed over time from patient navigators to care coordinators, etc.?
A: I think the word “case” was always there because the insurance companies would “refer you a case;” I first started to hear the term “case manager” in various states’ Departments of Insurance.  As long as I have known about case management, I have associated it with advocacy, care coordination, and resource management. Even when I entered the field as a ‘rehab nurse,’ I knew that the profession of case manager was evolving, and there was a need to distinguish the education and experience of the professional who did this work. In the late 1980’s, talk started to ensue among the rehabilitation nurses, the certifying agencies, and other professions with great debate about who would qualify to sit for an exam to be a ‘case manager.’ Simultaneously to this, we started to see case manager roles expand inside the hospitals, among payers, and self-insured employers themselves. Components of utilization management, hospital bill auditing, and care coordination became requests of those in this field.  I have seen the new titles of care coordinators and navigators, and I am pleased when I see the job descriptions that often state, “CCM preferred.” The certification attests that you meet a certain competency and experience level to sit for the exam. We do help patients and families navigate complex systems. We do coordinate care. Case management is about making things happen!

Q: How are case managers patient advocates? What is vital about this role in the health care system?
A: In addition to their clinical experience, the case managers have training in the benefit systems and reimbursement systems that pay for the services. Helping patients access their benefits and manage those benefits effectively is often critical to the outcome. Advocating for quality care, access to care, and even evidence-based care, is part of the advocacy. Sometimes it’s as simple as getting people involved in the patient’s care to listen—to take a pause and think about what the patient is trying to say or wants.  In a world that is stressing value-based care and quality performance measures, the case manager role becomes more vital. We are vital to driving quality health care, helping manage benefits at the right place, right time, etc., and ultimately to the cost management of large populations.

Q: Can you describe an important case you’ve worked on?
A: One that always stands out in my mind was a victim of a mass shooting known as the Standard Gravure Shooting in Louisville, Ky., in 1989.  It’s important to me because gun violence and violence in the work place has become a weekly headline.  But this event drew national publicity.  Within hours of the shooting, I was being called to be the case manager for some of the victims. One was a gentleman who had worked in the plant over 40 years. This wasn’t just a patient with serious physical wounds, but one with emotional trauma. I remained a part of his case until the day he returned to work, which was his personal goal. I followed him the first year in his new job.  But this patient, this case, changed my awareness of the importance of integrating physical and behavioral health into care planning. 

Q: What is the biggest challenge related to case management?
A: Establishing trust with patients.  Today we talk about “patient experience” and “patient engagement” and this applies to case managers as well. Many patients or families initially see you as the person who is coming to take something away. It takes skill to help a patient with complex issues to understand that you are there to assess the situation and can actually help. There are also challenges in health reform itself and the demand for quality case managers. 

Q: I understand you helped write t sample test questions to become a certified case manager in the 1980’s. How has this specialty evolved since then?
A: Back when case management started, it was very episodic. Up until the early 1990’s, you would take one case, then another, and we thought that receiving a case referral six months after a diagnosis or three months after an injury was “early.” It used to be based on the idea that something had to have already happened. Now, I’m looking out across the population with predictive analytics information on a subset of that people in a community and trying to identify where I could best place a case manager.

An additional change is the growing numbers of certified case managers. The recognition of case managers in the continuum of health care has been part of the evolution. They are valued as key members of the team, in whatever setting. Case managers have started to be identified as part of the preventive services, not just a referral after a catastrophic event.

Q: Why should nurses in other practice areas pay attention to National Case Management Week and what are some ways nurses can celebrate?
A: National Case Management Week, like other specialty recognition weeks, affords an opportunity to learn about nurses and other professionals who are part of an integrated care team. Gaining insight into the training, the various job roles, and what a case manager can “make happen” could help other nurses collaborate with this key person on the team.  It might even help nurses who are interested in the specialty of case management find an open door.

Q: What do you see for the future of nurses and case managers?
I see that the role of nurses in general has really come back to that primary care model. We want to coordinate end-to-end care for the patient, and I think the future holds more case managers taking the lead coordinating for the patient across the entire continuum of care. I see unlimited possibilities, but I certainly see an increased demand not just for nurses, but for case managers. Technology will also continue to play a big role. The skill sets have changed and over the years I’ve hired 2,000 case managers in a variety of settings, and I can tell you that the skill sets to do this work require so much knowledge about the software for the documentation and for the reporting. Plus, many of our case managers are virtual, so the settings will continue to change. A person needs to survive in a virtual workforce.