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
A View from the Field: Career Advancement Through Clinical Ladders
By Vicki West, RN, BSN, CCM
Today’s health care industry is challenged with maintaining economic viability by controlling costs and maximizing reimbursement while
delivering premium services and ensuring patient safety. To assist in meeting these obligations, case managers are expected to go beyond the
scope of the traditional job descriptions.
Neither a nurse nor social worker and longe carry out assembly line
tasks of matching predetermined solutions to the needs of our patients
and families. Many have developed exceptional talents of creating
alternative solutions for uncommon circumstances. Others find their
calling in diverse fields such as data analysis, community service and
representation, leadership, education or staff development. This is why
clinical ladders can work so well in case management practice. A well-
designed clinical ladder program allows a case manager to personalize
their job assignment with a preferred domain of expertise or interest. It
also ladder offers economic incentives for participation in selected
activities and projects that benefit the employee, the organization and
ultimately, the patients.
Zimmer introduced clinical ladders for nursing in 1972 with a focus
on expertise of the nursing process.1 During the nursing shortage of the
1980s, clinical ladders were put in place to address retention and
recruitment deficits. Throughout the years, various models have been
devised and adopted. Many nursing advancement programs were
designed using Benner’s model of novice to expert as a basis.2 Benner
stressed experience, skill knowledge and demonstration of those
anticipated skills. The concepts of the Carper’s “knowing of nursing”
have also been integrated into other advancement programs.3
Few tracks lead to promotion or salary increases for case managers
unless they seek an administrative or management position. Clinical
ladders for case managers offer financial opportunity and professional
growth for those who prefer to stay at the bedside. This is an important
retention strategy.
TWO MODELS OF CASE MANAGEMENT LADDERS
Documentation of case management clinical ladders is limited in
literature. Haas and Hackbarth describe a clinical ladder program that
placed emphasis on mastery of skills, behavioral roles, and continued
education.4 Their model was aimed at nurse case managers in an
ambulatory care setting. The case manager must demonstrate mastery of
behaviors and skills of one level before advancing. The authors suggest
that criteria of the advancement program be integrated into the job
description as well as used as a “performance appraisal instrument.”
Another example of a clinical ladder, or progression program, is one
that emphasizes personal achievement, active participation in quality
improvement projects and contribution to community rather than
demonstrating behaviors and skills. Participation can be voluntary. After
meeting eligibility requirements such as two years case management
experience, successful new employee probationary period and no
disciplinary actions with the past two years, the staff member may
participate in the first level of the progression program. An application
with an outline of three proposed activities is submitted for approval to
management or a review panel. The projects may include undertakings
6
such as mentoring, chairing or actively participating on a committee,
educational presentations, community service, certification relating to
the case management field, or negotiated activities. At the end of the
year, a portfolio containing documentation of the work and outcomes is
presented for review. If approved, the participant will receive compensa-
tion equal to five percent of their base salary. After successful completion
of Level One, the employee may apply for Level Two (requiring four
activities), reapply for Level One status, or opt out of the program.
Compensation for Level Two is elevated to ten percent of the base salary.
BENEFITS OF A CLINICAL LADDER PROGRAM
A well-planned clinical ladder program offers many benefits to the
employee. Many participants may say that the supplemental income is a
primary incentive for participation. Recognition for a job well done is
also important to most. Case managers can and should use these
programs to market themselves as valuable assets to their employers,
showing off their skills and talents. Progression programs challenge case
managers to broaden their boundaries and enhance their careers. Case
managers may be drawn into areas of their organization, health care,
education, community or other vocations that otherwise they would not
venture. The variable assignments can be appealing. For example,
someone with a preference for performance improvement projects
might participate as a member of a committee or individually, to identify
system problems, audit the situation, trial proposed solutions and
activate a more efficient modification.
The positive impact of clinical ladders extends to the employer as well.
Obvious advantages are the effects upon retention and recruitment. The
health care industry spends significant amounts of money every year on
retention and recruitment. In Keeping the People Who Keep You in Business:
24 Ways to Hang on to Your Most Valuable Talent, Leigh Branham estimates
the cost of turnover may range from 25 to almost 200 percent of an
employee’s annual compensation. The author states that the cost of hiring
and training a new employee may range from a few thousand dollars up to
$75,000. If a progression program is successful in retaining valuable staff,
the expenditure of incentive pay is minimal in comparison.
The employers’ advantages also extend to improvement of
productivity. Participation in clinical ladders encourages efforts which lead
to common purpose and increased commitment to the organization. As a
result of case managers’ experience and knowledge of effective patient
management,they are expert resources to lead and serve in initiatives such
as performance improvement, cost containment projects, and disease
management programs.
BARRIERS TO CLINICAL LADDERS
Participation in a clinical ladder requires additional allocation of time
and energy to appropriately complete the selected tasks. Many of the
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approved activities require the employee to invest personal time. Case
managers may choose to opt out of the progression program for various
reasons. Personal obligations related to family, continued education or
side interests may take priority over clinical advancement. To ensure
success of the program, the employee should feel no obligation to
participate and have no fear of penalization for exemption.
For the employer, the main disadvantages appear to be time and
cost. The primary expense of implementing clinical ladders is generated
in the process of developing and maintaining the program. Whether
overseen by a human resource department or case management
personnel, administrators are required to spend time promoting the
program, meeting with employees, reviewing the applications and
portfolios and completing the processes for awarding the incentive pay.
The added expense of the incentive awards may stretch already strained
fiscal budgets. However, this expense should be viewed in the context of
the revenue preserved by case managers who diligently and effectively
ensure the appropriate patient services are delivered in timely and cost
effective manners.
SUMMARY
Clinical ladders have been used successfully in nursing for decades.
This process can easily be modified for nurse and social worker case
Negotiating Lower Rate Reimbursement (continued from page 3)
The hospital’s criteria for medical necessity and the physician
advisor’s determination are important in making this decision. If it is
determined that continued hospitalization is justified, the case
management department should use all denial prevention strategies,
such as expedited appeal, while the patient is still in the hospital.
For example, some hospitals have experienced denials or offers of
skilled facility rates for patients on IV heparin drips, yet this service is not
available in any facility within the plan’s network, nor is it considered a safe
practice in the region. In such a case, opting to appeal a denial rather than
accepting a lower rate reimbursement is a better strategy, because denial
appeal has a high likelihood of success. On the other hand, a hospital might
opt for lower reimbursement if, because of delays in discharge planning, a
nursing home bed is not available for the patient when hospitalization at
the acute level of care is no longer medically necessary.
MONITORING FOR PERFORMANCE IMPROVEMENT OPPORTUNITIES
Monitoring the reasons for accepting lower rate reimbursement is
critical. Monitoring can reveal trends or patterns of inefficient
utilization management and discharge within a facility. It can also reveal
under-utilization or unavailability of lesser levels of care, such as skilled
nursing units. Case management departments are advised to provide
regular reports of analyzed data to their chief allies, as a good approach
to problem solving. The utilization management committee, managed
care contracting department and administration will consider this
valuable information. It is helpful for determining strategic goals,
developing hospital-wide utilization management protocols, and
establishing agreements with external facilities.
managers. Participants advance their careers by expanding their
influence and showcasing their special skills and talents while receiving
incentive compensation. Clinical ladders prove to be beneficial
influences in retention and recruitment. Productivity increases when
case managers develop vested interests in system-wide issues and
projects. In the end, a successful clinical ladder program will benefit the
case manager, the employer and the patients.
ABOUT THE AUTHOR
Vicki West RN, BSN, CCM is the Trauma Case Manager at WakeMed
Health and Hospitals, Raleigh, North Carolina. She received an Associates
Degree in Nursing from Palm Beach Community College and a Bachelors
of Science in Nursing from the University of North Carolina. She received
her case management certification in 2002.
1. Zimmer M. Rationale for a ladder for clinical advancement.
J Nurs Adm. 19722; (6):18-24.
2. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice.
Menlo Park, Calif: Addison-Wesley; 1984.
3. Carper BA. Fundamental patterns of knowing in nursing [dissertation].
New York, NY: Teachers College, Columbia University; 1975.
4. Haas SA, Hackbarth DP. Dimensions of the Staff Nurse Role in Ambulatory Care:
Part IV- Developing Nursing Intensity Measures, Standards, Clinical Ladders,
and QI Programs. Nursing Economics. 1995; 13 (5): 285-294.
For instance, a high number of negotiations completed due to late
discharge planning may call for changes in the case management
department’s method of identifying high-risk patients. Negotiations
necessitated by a lack of appropriate beds may call for priority agreements
between the hospital and local skilled nursing facilities. The managed care
contracting department may want information about lower rate
reimbursement when negotiating a new contract or reimbursement rates
with a payer. A high number of patient days paid at a lower rate
reimbursement may prompt an insurance plan to request deeper
discounts, as it may be viewed as ineffective utilization management.
TERMINOLOGY CAN BE CRITICAL
Finally, a note of caution: the use of the phrase “lower rate
reimbursement” is an important point. For hospitals not licensed to
provide the skilled nursing level of care, “lower rate reimbursement” is
most appropriate. Hospitals may want to avoid the use of “skilled rate
reimbursement” or similar terms in contract language or staff
discussions with insurance plans, to prevent misunderstanding,
conflict, and potential licensing issues.
ABOUT THE AUTHOR
Cynthia Beemsterboer, RN, BSN, ACM is Manager of Case Management at
Northwestern Memorial Hospital in Chicago. Her experience in case
management and utilization management spans more than 20 years. She
is a frequent speaker and trainer at case management and denial
management conferences. Ms. Beemsterboer earned her BSN degree at
Valparaiso (Ind.) University.