CDC adds CM policy to screening program
CDC adds CM policy to screening program
Feds recognize value of case managers
The federal government recently gave case management its stamp of approval when the Centers for Disease Control and Prevention (CDC) in Atlanta developed a case management policy for its National Breast and Cervical Cancer Early Detection Program. Over the past 10 years, the program has provided breast and cervical cancer screening to more than 2 million uninsured and underinsured women.
The CDC administers the funds that pay for screening programs in each of the 50 states, as well as several U.S. territories and Native American reservations. "What we can’t use the money for, according to the legislation which established the program, is to provide treatment for women identified as having cancer," explains Amy DeGroof, a health education specialist with the CDC.
"However, because of concerns over the difficulties the states have in getting women into treatment once they’ve been diagnosed with a cancer, the legislation was amended to provide funds for case management," she says.
Each state and local program is responsible for finding and monitoring treatment for women who have positive cancer screens, but the CDC developed its case management policy to give local programs guidance as they develop their own case management efforts. "We can’t dictate at the federal level how each program must integrate case management into its existing services. We’ve developed a general policy around case management to help programs define and develop their own plans for implementing this new mandate."
The legislation that authorized the establishment of the program did not specifically reference case management as a program component. However, in 1998, Congress modified the legislative authority of the program to include case management for all enrolled women with an abnormal screening result or with a diagnosis of cancer. Abnormal screening results requiring case management intervention include:
• a clinical breast exam with a discrete palpable mass, bloody or serous nipple discharge, nipple or areolar scaliness, skin dimpling or retraction;
• a mammogram with a suspicious abnormality worthy of biopsy, an abnormality highly suggestive of malignancy, or an incomplete assessment requiring additional imaging evaluation;
• an abnormal pap test including high-grade squamous intraepithelial lesion and squamous cell carcinoma.
In addition, the CDC case management policy recommends that case management be considered for the following women:
• those who fail to respond to rescreening reminder system after a previous normal screen;
• those with a previous history of abnormal screening results;
• those whose results require short-term follow-up;
• those who demonstrate a lack of timely response at any stage of the screening and diagnosis process;
• those who request case management or whose physicians request it.
"The new legislative mandate recognizes the potential of good case management strategies to help eliminate the logistical, financial, and other barriers that lengthen the period of time women wait before getting the treatment services they need," notes DeGroof.
As it began to work on its case management policy, the CDC contacted case management associations, industry leaders, case management researchers, and state program directors in the field for advice. "We have been advising the CDC leaders since last year," says Kathleen Moreo, RN, BSN, CCM, CDMS, president of the Case Management Society of America (CMSA) in Little Rock, AR.
"Our goal has been to assist the CDC in formulating appropriate guidelines as they roll out their mandate for case management intervention among our nation’s under served populations," adds Moreo, who spoke at the annual meeting of directors of the National Breast and Cervical Cancer Early Detection Program held recently at the CDC to introduce the case management policy. "We find it very encouraging that the CDC incorporated the CMSA Standards of Practice’ into its new case management policy."
"The standards of practice don’t provide a hidden treasure map to help these local and state programs find easy treatment solutions for these uninsured and underinsured women," says Nancy E. Skinner, CCM, RN, immediate past president of CMSA. "These programs have a unique dilemma. Congress is funding the screening of these women, but not the treatment. Essentially, under the new mandate, Congress has challenged case management to find creative solutions. And I believe that good case management strategies integrating the four hallmarks of case management — assessment, planning, facilitation, and advocacy — will help these programs succeed."
The CDC adapted its case management policy from the CMSA standards of practice, the case management standards of the Washington, DC-based National Association of Social Workers (NASW), and policies developed internally by other CDC-sponsored programs. "The CDC appreciates the support of the professional organizations and case management experts. They have all been important resources to us. We’re very grateful to both CMSA and NASW," says DeGroof.
The policy identifies these six case management functions:
1. Assessment. This function is defined as an appraisal of program and community needs and a cooperative effort between the client and case manager to examine the needs of each individual client.
2. Planning. This encompasses assessing provider preparedness, the assurance that program resources are available to meet the needs of clients, and the development of an individual client plan for meeting immediate, short-term, and long-term needs.
3. Coordination. This includes the establishment and tracking of case management systems and the brokerage, coordination, and referral of services to meet the needs of the client as outlined in the client plan.
4. Monitoring. This is defined as the reassessment of the case management systems and operational plan and as the ongoing reassessment of the individual client’s needs and progress.
5. Resource development. This includes the establishment of formal and informal agreements with providers of screening, diagnostic, and treatment resources, as well as promoting self-sufficiency and self-determination among clients to help women gain the knowledge and support needed to obtain services in the future.
6. Evaluation. This includes both evaluation of the effectiveness of the case management system and the assessment of client satisfaction, timeliness of referral services, and quality of individual client plans.
Several stats already provide case management services. Texas has offered underserved women case management since 1994. "We contract with a number of groups, including county health clinics and the local office of Planned Parenthood, to do both screening and case management. What case management looked like in each area depended a great deal on what group was providing it," says Karen Knox, MS, LPC, case management director with the Breast and Cervical Cancer Control Program of the Bureau of Women’s Health in the Department of Health in Austin.
A pilot program funded in 1996 added additional case management staff to the program contractor in the San Antonio area. "San Antonio was a great test area because it incorporates five screening contractors and includes some very impoverished and also rural areas," says Knox. "Through the pilot, we were able to demonstrate that case management greatly reduced the time intervals between screening, diagnosis, and treatment."
The program mandates case management for any woman who has an abnormal screen that indicates a cancerous change, she says. "In some cases, case managers provide a needs assessment, help women make appointments, and follow up to make sure appointments were kept. The program also requires that treatment be initiated. That’s the real challenge. There’s a great need for the advocacy role of case managers here.
"In some areas, there is simply no one for case managers to refer women to. Sometimes, they find themselves negotiating with physicians and hospitals to donate operating rooms or surgical services."
The Texas program carefully tracks all in-kind contributions, she adds. "Case management has a lot of critics. We know that if we’re going to keep these new funds to pay for case management services, we have to be able to demonstrate case management strategies get results. We are developing systems to measure in-kind contributions because, more than anything else, [they] demonstrate what case management can accomplish for these women. If the CDC had to pay for the treatment our case managers are able to obtain for the women who need them, there would be fewer dollars for screening and early detection."
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