Legal & Regulatory Issues

Legal & Regulatory Issues Title Protection for Professional Case Management: Social Work’s Intricacies and Opportunities Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP

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ase managers have a list of items to master upon entering the workplace. These range from job specific functions, performance metrics specific to their role, daily routines, plus electronic record systems, and technology platforms. However, knowing why title protection is so critical to his or her role as a professional case manager is not usually on the radar. Given the burgeoning importance of credentialing and public protection to health care industry stakeholders, title protection should be an immediate priority. There has been considerable focus in the literature over the years on title protection for case management (Graham-O’Gilvie, 2013; Muller, 2013; Powell, 2011, 2014; Professional Case Management Editorial Review Board, 2009; Treiger & Fink-Samnick, 2016). The concept has been motivated by a number of factors including the multiplicity of case management titles and roles, plus the interplay of the primary role of credentialing and public protection (Powell, 2011; Treiger & Fink-Samnick, 2013). Health and behavioral health job markets have exploded, with a tsunami of case management-related titles, roles, functions, and job descriptions spanning business Disclaimer: The information contained in this department is for educational purposes only. It is not legal advice, which can only be given by an attorney admitted to practice in the jurisdiction/ state(s) in which you practice. Do you have a question or issue you would like addressed here? Questions are always welcome. We encourage ALL readers to submit questions and/or manuscripts, as well as topics you would like to see addressed in this department. Questions and other inquiries are accepted by e-mail at: [email protected]. If you have an idea you would like to discuss, send your contact information by e-mail and you will contacted by your preferred method. Address correspondence to Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP ([email protected]). The author reports no conflicts of interest. DOI: 10.1097/NCM.0000000000000169

models across practice settings. Experts challenge that this expansion has contributed to a paradoxical effect on case management’s identity as a profession (Treiger & Fink-Samnick, 2013). With respect to consideration of title protection for professional case management, the complexity of social work education and licensure pose grand challenges. There are impeding factors; not every state legislates licensure for all social work roles, such as those hired by public institutions and the exemptions existing in certain practice settings (Treiger & Fink-Samnick, 2016). Societal trends factor in, including how momentum toward expanding licensure has increased as insurance companies require formal licensure for professionals who submit for third party reimbursement or participation in a managed care network. Then add the overbearing public protection concerns identified for health care stakeholders, who strive to understand why not all those with the title of social worker are actually educated and/or licensed as social workers. Countless intricacies underlie social work practice around the globe. To that end, the primary focus for this article is on social work’s education and licensure and how these topics influence the way in which title protection for professional case management moves forward.

Title Protection 101 While the language of the title protection laws across states and jurisdictions differs, the theme is somewhat uniform (American Nurses Association [ANA], 2016a; Legislative Tracking System, 2014; North Carolina Social Work Board, 2014). It speaks to a legal designation where it is unlawful for an individual to call himself or herself by a specific professional title without the requisite education and training for that title, plus potentially the minimal level of licensure (Treiger & Fink-Samnick, 2016).

Nurse Title Protection In comparison, at least 39 states have language included in their Nurse Practice Act specific to title protection. The language is either explicit in restricting use of the title “nurse” to those who are licensed

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Legal & Regulatory Issues or there is implicit language restricting use of any words implying the individual is a licensed nurse (ANA, 2016a). The exact language for each state appears in a grid on the ANA Nursing World website (ANA, 2016b). The topic is well represented across the literature (Graham-O’Gilvie, 2013; Muller, 2013; Powell, 2011, 2014; Treiger & Fink-Samnick, 2013, 2016). One thing both nurses and social workers have in common is that social workers have no blanket multistate practice ability, nor reciprocity. There are exemptions for those employed by the military, but, by and large, even endorsement requires social workers to re-apply for licensure in each new state or jurisdiction where they would like to practice. If you are interested in recent discussion of the Nurse Licensure Compact, which now includes 25 states (see Fink-Samnick & Muller, 2015).

Social Work’s Quandary Although an advancing trend, title protection has been a difficult journey for social work. It has been motivated by assorted factors from public protection to recognition of social work as a specialized profession and not just a job title (Treiger & FinkSamnick, 2013). Although many countries and states have laws to regulate and protect the title of “social work,” it is not necessarily formal title protection legislation. However, several countries have moved forward with laws to protect the social work title, including Belgium, Finland, Germany, Iceland, Malta, Poland, and Slovenia (Hussein, 2011). The United Kingdom passed title protection under its Care Standards Act of that year. As stated in Chapter 14 (Part 1V) Section 61, “No one can describe herself or himself as a social worker unless he or she is registered in the Social Care Registry maintained by the General Social Care Council” (Murray & Hendricks, 2011). In the United States, at least 37 states have title protection for social workers (Wright, 2013). Assertive efforts have been the focus of public policy initiatives in other states, including California and Massachusetts. A majority of states with social work licensure have an administrative law and/or regulation that protects use of the title “social worker” by use from anyone who is not a “social worker” (Social Work Examination Services, 2016). The following topic areas address the most common queries I receive from colleagues as they work to decipher why social workers are as distinct as apples and oranges. Providing a foundation of social work education and licensure will contribute to defining a clearer path for the professional case management designation.

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Not All Master’s Prepared Social Work Degrees Are the Same The Council on Social Work Education (CSWE) is a national association of social work education programs and individuals that ensures and enhances the quality of social work education. The association maintains the national accreditation standards for baccalaureate and master’s degree programs in social work, by promoting faculty development, engaging in international collaborations, and advocating for social work education and research (CSWE, 2016a). As of March 2016 there were: • 511 accredited baccalaureate social work (BSW) programs; • 245 accredited masters’ social work (MSW) programs; • 15 baccalaureate social work programs in candidacy; and • 16 masters’ social work programs in candidacy. (CSWE, 2016b) A growing number of online programs are amid the accreditation process as well, with the University of Southern California School of Social Work one of the few CSWE-accredited online MSW degrees in the country. Most states mandate a degree from a CSWEaccredited school to fulfill the educational requirement for licensing (SocialWorkLicensure.org, 2016a). Baccalaureate, master’s, and doctoral level education comprises social work’s professional career ladder. For the purposes of this article, the focus is on the first two levels. CSWE defines nine competencies for baccalaureate and master’s education, which serve to establish thresholds for professional competence (CSWE, 2015). The competencies are presented in Box 1.

BOX 1 Council on Social Work Education (CSWE) EPAS Competencies Competency 1: Demonstrate Ethical and Professional Behavior Competency 2: Engage Diversity and Difference in Practice Competency 3: Advance Human Rights and Social, Economic, and Environmental Justice Competency 4: Engage In Practice-informed Research and Researchinformed Practice Competency 5: Engage in Policy Practice Competency 6: Engage with Individuals, Families, Groups, Organizations, and Communities Competency 7: Assess Individuals, Families, Groups, Organizations, and Communities Competency 8: Intervene with Individuals, Families, Groups, Organizations, and Communities Competency 9: Evaluate Practice with Individuals, Families, Groups, Organizations, and Communities

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Legal & Regulatory Issues The Baccalaureate Social Worker BSWs may engage in a primary level of case management practice (e.g., intakes and preliminary assessments, resource coordination) or potentially macrolevel roles in community organization or program management. Although those with a BSW degree may be allowed to offer counseling in limited circumstances, they will most likely not be permitted to engage in psychotherapy or private practice. States tend to limit clinical social work to master’s trained individuals, even when working under supervision (SocialWorkLicensure.org, 2016b).

The Master’s Social Worker Master’s level education traditionally occurs over 2 years: a primary year for foundational elements and a concentration year for candidates to focus learning on either clinical or nonclinical concentrations or tracks. These (two tracks) are conventionally known as clinical and social change, or micro and macro, respectively. Some programs offer specialties (e.g., youth, family) or subspecialties (e.g., geriatric populations and veterans) (SocialWorkLicensure.org, 2016c). MSW candidates may also be eligible for advanced standing programs, which are usually open to students who have received a BSW degree from a CSWE-accredited program. These students may move immediately into the advanced competencies and/or specialized study open to concentration year students (SocialWorkLicensure.org, 2016c). Social Work Licensure Is Not the Same Across All States There are as many roles for social work within today’s case management models, as there are case management titles. However, independent of the role defined for social work, the ultimate scope of practice is defined by that individual’s licensure. States that regulate social work practice define the scope of that practice. An enormous challenge comes from the public sector, where state and county offices traditionally hired individuals to fill social worker positions without the requisite education or training. In fact, many states do not require publicly employed social workers to possess a license (Social Work Examination Services, 2016). Public agencies have a powerful lobby, which has been known to resist legislative efforts to broach title protection at the state level. Among the concerns voiced by these particular entities are those specific to the potential expense incurred to educate and license individuals in a social work role. Social work professionals recognize how requiring higher standards of education

and credentialing for the purpose of title protection enhance public safety. However, that view is not shared across the states. A similar challenge exists with states that have licensure exemptions (§ 54.1-3701 and § 54.1-3709; Virginia Board of Social Work, 2015) As a result, social work licensure may not be mandated or required for individuals employed in certain practice settings (e.g., nursing homes, hospitals, hospice). As a result, a “social worker” employed in a nursing home may have a degree outside of the health and human services, such as in Business or Education. This may very well translate into that individual not necessarily having the CSWE-accredited education in key areas endemic to social work practice. This poses a serious challenge to public protection, and why credentialing and title protection remain one of the hottest topics for discussion among health and behavioral health professionals. Not All Levels of Social Work Licensure Allow for Independent Practice The Association of Social Work Boards (ASWB) develops and maintains the four categories of social work licensure examinations across the United States and Canada. These examinations are: • • • •

Bachelor’s Master’s Advanced generalist, and Clinical. (ASWB, 2016)

Not every state and/or jurisdiction uses all four categories, with that determination defined by each licensure board.

The Licensed Clinical Social Worker The clinical level of social work practice is the one that is consistently regulated across all states and jurisdictions. It is the highest level of licensure awarded to social workers and may also be known as “independent” or “independent clinical.” Some states have both independent and independent clinical levels. (SocialWorkLicensure.org, 2016d). A confusing point exists in the variation of credentials used across the social work profession. For example, the independent or clinical level of practice is an LCSW in Virginia, an LCSW-C in Maryland, and an LICSW in the District of Columbia. Given the variations in credentialing and scope of social work licensure across the states, the most accurate place to view the scope and requirements for each licensure level are the websites for each individual state board. Table 1 provides the levels of social work practice regulated, along with the common credentials used.

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Legal & Regulatory Issues TABLE 1 Levels of Social Work Practice Regulated Associate license

Qualifications require 2 years of college or an associate’s degree. Some states also specify 1 or 2 years of experience. Candidate qualifications vary from state to state. The license may be called an LSWA, LBSW, SWT, or similar names.

Bachelor’s examination

The name and qualifications for this level of licensure vary from state to state. It may be called an LSW, SW, LSWA, BSW, or others. The license requires a bachelor’s degree in social work or a bachelor’s degree and specific periods of experience.

Master’s examination

This level of licensure is only available to social workers who have received an MSW. Many states award this license immediately after graduation. Some states permit the candidate to take the examination a few months before graduation. The license may be called an LCSW, CISW, LGSW, CSW, LMSW, or LSW, depending on the state.

Clinical examination or advanced generalist

This level of licensure is only available to social workers who receive the MSW or DSW degree and have a specified number of years or hours of post-master’s supervised experience. Some states award this license upon graduation with completion of the clinical level examination. This licensure is often known as “provisional licensure” with practice restricted until the specific hours of supervision and other state-specific requirements are met. It may be called a CSW, PIP, LCSW, LCSW-C, LSCSW, BCSW, LICSW, or LISW, depending on the state.

Note. From Regulatory Issues, by Social Work Examination Services, 2016. Retrieved March 2, 2016, from http://www.swes.net/regulatory.html.

Why the Term “Professional Case Manager” Is Vital for Title Protection Case managers have long debated what the entry-level case manager looks like on the basis of education and experience and who can call themselves a case manager. It is more than a discussion of title protection, but rather one of education, profession, case management process, scope of practice, and standards of care (Muller, 2013). In no greater way does this play out then in considering the most appropriate language in the context of title protection for social workers engaged in the professional case management workforce. Merriam-Webster (2016) defines profession as: a. A calling requiring specialized knowledge and often long and intensive academic preparation. b. A principal calling, vocation, or employment. The terms “profession” and its corresponding adjective of “professional” are woven throughout case management’s administrative foundation. Grounding documents frame case management as a professional, collaborative, and interdisciplinary practice. Board-certified case managers are referred to as professional case managers who possess the education, skills, moral character, and experience required to render appropriate services based on sound principles of practice (Commission for Case Manager Certification, 2015). The Case Manage-

“Social work’s licensure complexities make title protection for professional case management cumbersome, but far from impossible.” 204

ment Process (Powell & Tahan, 2008), which serves as the template for a case manager’s workflow, is carried out within the ethical and legal realm of that case manager’s scope of practice, using critical thinking and evidence-based knowledge (Case Management Society of America [CMSA], 2010). Reference to the ethical and legal domain is akin to the regulatory scope of practice, which underlies the primary licensure and/or certification of each health care professional, as well as the principles, rules, and guidelines, to denote case management certification. Social work’s licensure complexities may make title protection for professional case management cumbersome, but far from impossible. It is understood that social work professionals who engage in case management practice meet CMSA’s qualifications standard (CMSA, 2010). As amended and updated in 2011, this standard clearly states the need for case managers to have a “current, active and unrestricted licensure or certification in a health or human services discipline that allows the professional to conduct an assessment in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline” (CMSA, 2010, p. 19). Those circumstances in which a state does not require licensure or certification are also addressed by requiring the individual to have a baccalaureate or graduate degree in social work or another health and human services field. Although the BSW degree does not also allow for independent practice in many states, it sets a minimum standard for knowledge, which one can advance from to attain independent licensure and ultimately eligibility for case management certification. (CMSA, 2010).



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Legal & Regulatory Issues “CMSA is actively supporting and encouraging title protection for professional case management.” The language of CMSA’s model act is equally compelling. It states, “Case managers are health care professionals and pioneers of health care change. They serve as health care team leaders that open up new areas of thought, research and development. Case Managers positively impact and improve consumer well-being and health care outcomes” (CMSA, 2011, p. 1). Despite the convoluted nature of professional licensure, title protection for professional case managers is a viable option and necessity, with the word “professional” an essential component. There is a clear distinction in use of the verbiage “professional” to denote this level of practice. Case management’s historical challenge to be viewed as a profession, as opposed to solely an advanced practice of nursing, is referenced in the literature (Treiger & Fink-Samnick, 2016). Framing the context of practice from a “professional” lens sets a higher bar for accountability for all involved, with public safety more readily assured.

Moving Forward As the professional association for case managers, CMSA is actively supporting and encouraging title protection for professional case management, the culmination of public policy advocacy, which began with defining clear Standards of Practice for Case Management (CMSA, 2010) and development of the Model Act (CMSA, 2011). Title protection will advance public protection. These legislative efforts will solidify case management’s presence across the health care landscape by mandating a standardized comprehension of the role and competencies that define it. This way, only one who has achieved the education and credentialing eligibility requirements defined by regulatory entities to be a case manager may call themselves a case manager (Professional Case Management Editorial Review Board, 2009).

CONCLUSION It is understood that the professional case manager must be able to engage in independent practice. Case management, with its valued workforce of transdisciplinary professionals, has reached the moment where it must evolve from recognition for a task-driven job to a purpose-driven profession (Treiger & Fink-Samnick, 2016). To that end, the level of social work practice must reflect the education, qualifications, and licensure

that allows for independent assessment and practice. Defining this content will make billing and reimbursement for case management services meaningful, easier, and demonstrative of cost saving that today and tomorrow’s health care requires.

REFERENCES American Nurses Association. (2016a). Title “nurse” protection. Retrieved February 24, 2016, from http:// www.nursingworld.org/MainMenuCategories/PolicyAdvocacy/State/Legislative-Agenda-Reports/StateTitleNurse American Nurses Association. (2016b). Title “nurse” protection: Summary of language by state. Retrieved February 24, 2016, from http://www.nursingworld. org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-TitleNurse/Title-NurseSummary-Language.html Association of Social Work Boards. (2016). Exam content areas. Retrieved March 1, 2016, from www.aswb.org/ resources/?c=exam-content-outlines Case Management Society of America (2010, updated 2011). Standards of practice. Little Rock, AK: Author. Case Management Society of America. (2011). Case Management Model Act. Retrieved February 24, 2016, from http://www.cmsa.org/PolicyMaker/HealthCareReform/tabid/446/Default.aspx Commission for Case Manager Certification. (2015). Code of professional conduct for case managers with rules, procedures and penalties, Mount Laurel, NJ: Author. Council on Social Work Education. (2015). 2015 Educational Policy and Accreditation Standards for Baccalaureate and Master’s Social Work Programs. Alexandria, VA: Commission on Educational Policy and the CSWE Commission on Accreditation, Council on Social Work Education. Council on Social Work Education. (2016a). About CSWE. Retrieved March 2, 2016, from http://www.cswe.org/ About.aspx Council on Social Work Education. (2016b). Accreditation. Retrieved February 24, 2016, from http://www.cswe. org/Accreditation.aspx Fink-Samnick, E., & Muller, L. S. (2015). Case management practice: Is technology helping or hindering practice? Professional Case Management, 20(2), 98–102. doi:10.1097/NCM.0000000000000084 Graham-O’Gilvie, A. (2013). Is case management advanced practice? (Legal & Regulatory Issues). Professional Case Management, 18(6), 312–316. Hussein, S. (2011, November). Social work qualifications and regulation in European Economic Area (EEA). London, England: Social Care Workforce Research Unit, King’s College London. Legislative Tracking System. (2014). HB 2037. Retrieved March 5, 2016, from https://lis.virginia.gov/cgi-bin/ legp604.exe?111+sum+HB2037 Merriam-Webster. (2016). Profession. Retrieved March 2, 2016, from http://www.merriam-webster.com/dictionary/profession

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Legal & Regulatory Issues Muller, L. (2013). The future of case management (Editorial commentary Legal & Regulatory Issues). Professional Case Management, 18(6), 312–316. Murray, D., & Hendricks, G. (2011). A collaborative project to achieve title protection in North Carolina. The New Social Worker. Retrieved March 2, 2016, from http://www.socialworker.com/feature-articles/ practice/A_Collaborative_Project_to_Achieve_Title_ Protection_in_NC North Carolina Social Work Board. (2014). Statute Chapter 90B-16, title protection. Retrieved March 3, 2016, from http://www.ncswboard.org/ page/statute1#b16 Powell, S. K. (2011). The gestalt of case management. (Editorial). Professional Case Management, 16(5), 227– 228. doi:10.1097/NCM.0b013e318225d38d Powell, S. K. (2014). 2014 case management prognostications (Editorial). Professional Case Management, 19(1), 1–3. doi:10.1097/NCM.0000000000000006 Powell, S. K., & Tahan, H. A. (2008). Case Management Society of America (CMSA) core curriculum for case management (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Professional Case Management Editorial Review Board. (2009). The PCM Journal “Think Tank” on case management predictions (Editorial). Professional Case Management, 13(6), 239–301. doi:10.1097/01. PCAMA.0000341635.69074.72 Social Work Examination Services. (2016). Regulatory issues. Retrieved March 2, 2016, from http://www. swes.net/regulatory.html SocialWorkLicensure.org. (2016a). The importance of social work program accreditation. Retrieved March 2, 2016, from http://www.socialworklicensure.org/ social-worker-education/cswe-accreditation.html SocialWorkLicensure.org. (2016b). Why pursue a bachelor’s degree in social work. Retrieved February 24, 2016, from http://www.socialworklicensure.org/ social-worker-education/why-a-bachelors-in-socialwork.html#context/api/listings/prefilter SocialWorkLicensure.org. (2016c). Master’s level specialties, social work education. Retrieved February 24, 2016, from http://www.socialworklicensure.org/ social-worker-education/why-a-masters-in-socialwork.html#context/api/listings/prefilter

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SocialWorkLicensure.org. (2016d). Social work licensure requirements. Retrieved March 2, 2016, from http:// www.socialworklicensure.org/articles/social-worklicense-requirements.html Treiger, T., & Fink-Samnick, E. (2013). COLLABORATE: A universal competency-based paradigm for Professional Case Management, Part I: Introduction, historical validation, and competency presentation. Professional Case Management, 18(3), 122–135. doi:10.1097/NCM.0b013e31828562c0 Treiger, T., & Fink-Samnick, E. (2016). COLLABORATE® for Professional Case Management: A universal competency based paradigm. Philadelphia, PA: Lippincott Wolters Kluwer. Virginia Board of Social Work. (2015, July 1). § 54.1-3701. Exemption from requirements of licensure and § 54.13709. Unlawful designation as a social work, Chapter 37 of Title 54.1 of the Code of Virginia, Social Work (pp. 3, 6). Retrieved March 4, 2016, from https://www. dhp.virginia.gov/social/social_laws_regs.htm Wright, G. (2013, April 29). Title Protection Bill making progress in California, social workers speak. Retrieved February 24, 2016, from National Association of Social Workers website: http://www.socialworkersspeak.org/cheers-and-jeers/title-protection-billmaking-progress-in-california.html

Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, is Principal of EFS Supervision Strategies, LLC. She is an industry expert who empowers health care’s transdisciplinary workforce through professional speaking, mentoring, and consultation. Known and respected as “The Ethical Compass of Case Management,” she is a popular presenter and esteemed author with more than 70 publications across diverse media. With Teresa Treiger, Ellen is the coauthor of the book COLLABORATE® for Professional Case Management: A Universal CompetencyBased Paradigm, First Edition, published by Wolters Kluwer. She is also author of the Ethics, Social Media and Electronic Communication chapter for the Core Curriculum for Case Management, 3rd edition. Ellen’s passion is evident across her varied roles as professional trainer, educator, social media moderator, course and continuing education developer for distance learning, industry accreditation specialist, clinical social work supervisor, and professional mentor to the case management community.



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