C O L L A B O R A T I V E C A S E M A N A G E M E N T
Affecting Change from Daily Practice to Congress:
Legislative Advocacy and Case Management
By Jan DeRoche, RN, LCSW-C, ACM
The past decade has seen healthcare legislation significantly impact the daily practice of hospital case management. Initiatives such as
the Medicare Important Message (IM), Condition Code 44 (governing how a patient’s admission status may be changed from inpatient to
observation), and the Recovery Audit Contractor (RAC) program have required case management departments across the country to
evaluate and revise many of their current processes to adapt to this constantly evolving regulatory structure of healthcare.
In the midst of such initiatives and proposals, it is imperative –
perhaps now more than ever – that case management is represented
in the legislative process and case managers have an active voice in
the creation and implementation of regulations that will affect
patient care and organizations throughout the continuum of care.
ESTABLISHING A VOICE
To serve as an advocate in legislation, case managers must have
a voice that speaks for and represents those involved in the practice.
Without a legislative voice, the profession is left in a reactive
position, responding to regulatory changes rather than contributing
a unique operational perspective to their creation.
Case management is not a profession with a history of a strong
advocacy role at the legislative level. However, its influence in
certain, targeted initiatives has led to positive outcomes. Examples
of effective advocacy – case managers having a voice in the
legislative process – include the Centers for Medicare and Medicaid
Services’ (CMS) proposed revisions to the IM. When CMS
determined that Medicare patients must be issued a second written
notice, case managers across the country voiced their opposition to
the proposed change, and effectively saw the second IM reduced
from a written document to a verbal notification.
Case managers have a unique and valuable perspective to
contribute to policy making decisions. Serving as an advocate and
liaison for both patients and hospital administration uniquely
positions case managers to accurately reflect what the actual impact
of a particular initiative is going to be, and what the outcomes will be
for both the patients and the organization. The relationships that
case managers form with the various parties involved in care
delivery – patients, families, medical and nursing staffs,
administration, downstream providers and payers – provide them
with insight into the impact of regulations on patients, the hospitals
in which they are treated, and the care delivery system.
As patient advocates and proponents of patient rights, case
managers also have a duty to serve as the patient’s voice when
influencing legislation and decisions that may ultimately affect
patient care. Interpersonal relationships and experiences create the
credibility and voice of authority for legislative influence and action.
BARRIERS TO EFFECTIVE LEGISLATIVE ADVOCACY
AND INFLUENCE
A number of factors often present challenges to effective
legislative advocacy. The first of these is time. Large daily caseloads
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and demanding schedules often prevent many case managers from
allotting the time necessary to monitor legislative resources and
updates. This lack of time makes it difficult to stay abreast of
legislative changes and the issues that will impact case management.
Another barrier to case managers’ involvement in legislation is a lack
of knowledge of the legislative processes and procedures. For most,
it has been years since learning about these processes in a high
school or college civics class, and without periodic use this
knowledge fades. To engage actively in healthcare legislation, case
management professionals need to (1) actively track legislation that
affects healthcare and, specifically, case management, and (2)
formulate responses to those issues and regulations that warrant
action. The volume of legislative updates and information available
to case managers can be overwhelming, and the challenge is to
discern what information is relevant and warrants action. A number
of resources such as websites, e-newsletters, and email lists can
serve as valuable resources for staying current with legislative news
and updates (see sidebar on page 9).
Case managers have a unique and
valuable perspective to contribute
to policy making decisions. Serving
as an advocate and liaison for
both patients and hospital
administration uniquely positions
case managers to accurately reflect
what the actual impact of a particular
initiative is going to be, and what
the outcomes will be for both the
patients and the organization.
Perhaps the greatest barrier to engaging in legislative initiatives
is that many individuals in case management lack a feeling of
empowerment. Due to the nature of the practice, those who work in
case management are typically outcomes-driven individuals
accustomed to producing outcomes very quickly. Legislative
continued on page 8
 w w w . a c m a w e b . o r g
Affecting Change from Daily Practice to Congress: Legislative Advocacy and Case Management
processes, however, are often counter to this disposition. For
example, the ultimate goal of an initiative may be to ensure the
passing of a particular bill. This important goal, however, may
require months of work – even years if it is postponed until later
congressional sessions – and may be achieved at a much later date.
In order to stay motivated towards this goal, one should recognize
milestones, such as the first meeting with a congressional aide to an
influential representative, or phone calls made on behalf of your
cause or organization. Recognizing that these are milestones and
major steps towards reaching the ultimate goal will help maintain
the energy necessary to affect change.
KEYS TO EFFECTIVELY INFLUENCING LEGISLATION
Relationships with the Key Figures
One important component of case management advocacy at
the legislative level is establishing relationships with key legislative
figures. Who the key figures are may vary based on the issue
involved – for example, CMS officials when dealing with RAC or IM;
congressional representatives regarding the “Three-Midnight Rule”
(the Medicare rules that defines the length of a qualifying hospital
stay for a patient to be covered for placement in a Skilled Nursing
Facility); or state legislature when addressing issues within the state,
such as Medicaid coverage policies. With all, however, the key to
forming such relationships is demonstrating the value of the case
manager’s expertise. Accurately conveying one’s expertise builds
credibility and positions one as an expert resource on the topic.
Provide Relevant Data and Patient Stories
It is important to be equipped with sufficient, relevant data to
influence key policymakers. The ability to provide this information
may determine whether a particular initiative passes or is defeated
in its early stages. Considering RAC as an example, tracking the
amount of successful overturns and producing data outlining FTEs
and their relation to cost provides valuable, factual input.
Combining and analyzing this data to create a cost benefit analysis
also provides strong support to the position of placing limits on
RAC activities to ensure the resource costs to hospitals are not
unmanageable, and that the ultimate impact of the program is to
decrease the cost of providing healthcare to patients.
Though data can be a powerful tool and resource, patient
stories also play an important role because they put a human face
on the data and facts – reminding policymakers of the real
individual patients who are the intended beneficiaries of policy.
This is a particularly powerful tool when a policy has a negative
impact on patient care because first-hand accounts appeal to
emotions, and may trigger empathy for the situation in question.
These stories convey a deeper, underlying meaning behind the
position one is supporting, and are often more powerful in helping
policymakers understand processes and “real life at the bedside”
that they otherwise know only in the abstract.
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(continued from page 7)
Consistent, Incremental Approach
Another key component of legislative advocacy is consistency.
Working within the legislative process often involves a system of
trial and error – finding that the first method attempted to influence
legislation is not the best approach and exploring other methods to
achieve the same goal – until the desired outcome is achieved. It is
important to develop a consistent approach that continually strives
to achieve the ultimate goal of affecting change and that is a
sustainable strategy long-term, as affecting change often takes
multiple sessions of congress and may stretch over multiple years.
Such an approach recognizes incremental changes and evaluates
the small steps necessary to reach the ultimate goal, rather than
abandoning the cause in the face of resistance or difficulty.
Engage Others in the Effort
There is power in numbers – the more people who show their
individual support for a particular legislative effort, the stronger the
voice of the cause. Individuals build the strength of their voices when
their professional associations support legislative initiatives, and
associations attempting to influence legislation often grow their numbers
by forming coalitions with other associations. Two or three associations
speaking out in support of, or opposition to, a certain regulation or
bill is far more powerful and influential than one association because
the numbers of supporters, real or implied, are magnified further.
ACMA demonstrated this approach by partnering with the
National Home Infusion Association (NHIA) in 2007 to support the
expansion of Medicare benefits for home infusion. ACMA added its
voice by supporting NHIA’s lobbying day in Washington, D.C. and
building contacts in Congress. ACMA also used its membership to
seek patient stories that supported the initiative and
communicated these to key figures in Congress.
One of the associations that has been most successful in
influencing healthcare legislation is the American Association of
Retired Persons (AARP). AARP was instrumental in the initiatives
targeted at securing subscription and benefit coverage for Medicare
recipients. To achieve this feat, AARP established relationships with
some of the most influential congressional members and
candidates. The association also leveraged their extensive network
of members, and engaged them in the legislative goals and efforts of
the association. By doing so, AARP’s members helped craft the
public response to the prescription drug benefit plan.
AARP’s approach to legislative advocacy differs from the
approach best employed by case management. AARP leveraged its
large membership base and employed a populist approach to
legislative influence. Case management lacks such a vast
population. The most effective model for case management
advocacy will leverage case managers’ unique expertise and
experiential knowledge of healthcare policies. This allows case
management professionals to become valuable knowledge partners
to policymakers – unique experts in healthcare policy.
 C O L L A B O R A T I V E
Equipped with the Proper Tools and Skills
Perhaps the most important consideration when lobbying for
change in any area is that in order to most effectively influence
change, a reasonable solution must often be presented. While some
groups, such as Mothers Against Drunk Driving – have found
success advocating for an abstract concept such as safety – with the
complex challenges in the healthcare arena, it is not enough to
identify the flaws in a current process or program. In order for
legislators to consider a position, a reasonable solution or alternative
plan must also be presented and outlined. To revisit the RAC
example, approaching CMS and legislators with complaints about
the program’s cost to hospitals is not a sufficient case to sway their
opinion and bring about reform within the program. Though it is
important that case management professionals voice their concerns
during the comment period, to be effective advocates they must
approach CMS with an alternative solution in order to agree upon
a compromise that will satisfy those in the hospital setting, and will
still allow CMS to achieve their desired outcomes.
HOW TO GET INVOLVED
Individual case managers will rarely have access to key political
lobbyists and representatives, or the funds necessary to travel to
Capitol Hill. However, these factors need not limit their influence in
the legislative sector. There are a number of resources available and
actions which can influence change and effectively advocate on
behalf of the practice of case management, healthcare provider
organizations, and patients.
• Develop and maintain contacts with state and congressional
representatives – These individuals are the connection between
your local area and the legislative and regulatory bodies.
Contacts with congressional aides often lead to effective inroads
as well, as many lawmakers have limited availability due to their
tight schedules, and depend on congressional aides to be
experts in various areas. Visit www.usa.gov to locate state and
congressional representatives and access a variety of
government information.
• Maintain awareness and knowledge – Maintaining knowledge
of legislative happenings, agendas and pending decisions is
requisite to legislative influence. It is important to remain
informed of what committees are influential in healthcare
legislation and reform, and what bills are on the agenda and
may have some bearing on case management and patient care.
There are also several resources available online to summarize
information and provide links to further information, such as
reviews and updates available from CMS (www.cms.gov) and
the Federal Register (www.gpoaccess.gov).
• Join a group involved in legislation – Many professional
associations have committees and groups specifically focused
on monitoring and influencing legislative initiatives (such as
C A S E M A N A G E M E N T
Resources for legislative
news and updates:
• The Centers for Medicare
and Medicaid Services – www.cms.gov
• Fierce Healthcare –
www.fiercehealthcare.com –
offers legislative news and updates through
a number of email lists and e-newsletters
• National Conference of State Legislatures –
www.ncsl.org/statefed/health/HAC.htm
• U.S. Department of Health and
Human Services – www.hhs.gov
ACMA’s Public Policy Committee). Such groups engage
your energies with others who have a similar passion for
public advocacy.
CONCLUSION
As power in Washington, DC shifts more to one party and a
new administration begins its first term, healthcare legislation is
more prominent on the national agenda than ever before. New
legislation will be developed and implemented in efforts to
improve our nation’s healthcare system, and this legislation will
assuredly continue to affect case management. While case
managers will undoubtedly have various views about the best
solutions to common challenges, it is important in this crucial time
that the unique perspective and experience of case managers is
represented as new legislation is developed. Case managers have
proven their effectiveness to take on key challenges and produce
positive outcomes within their own healthcare organizations. It is
time for case managers to extend these solutions outside hospitals
and into the legislative process that will shape healthcare reform
for years to come.
Jan DeRoche, RN, LCSW-C, ACM, is the current ACMA National
President and Director of Case Management for Kaiser Permanente
Health Foundation of the Mid-Atlantic States in Rockville, MD. She
was previously Director of Case Management at Holy Cross Hospital
in Silver Spring, MD. She earned a BSN at Fitchburg State College in
Fitchburg, MA and her MSW at the University of Maryland at
Baltimore. She has over 25 years of healthcare experience.