The three levels of case management integration
Levels include low, moderate, and complex
Some of the key questions facing directors of case management today are: 1) How much integration is appropriate for the department? 2) Should one person handle both clinical case management and social work responsibilities? 3) What about utilization management?
Hussein A. Tahan, MS, DNSc(C), RN, CNA, director of nursing for cardiac specialties at Columbia Presbyterian Medical Center, New York Presbyterian Hospital in New York City, categorizes case management integration into three levels: simple, moderate, and complex.
Each category has its advantages and disadvantages. The categories of integration, according to Tahan, are defined based on the level of integration of the three main case management functions in the role of the case manager. The three functions are:
- Clinical care management as evidenced by the case manager’s involvement in care activities such as facilitation and coordination of the patient’s plan of care, tests and procedures, and patient/family education.
- Social work/services as evidenced by the case manager’s involvement in care-related activities such as psychosocial counseling, complex discharge planning, arranging for charity care, or health insurance coverage (e.g., Medicaid application).
- Utilization management as evidenced by indirect care activities such as managed care reviews, obtaining authorization/certification for care services, and ensuring that care is being provided at the appropriate level and in the relevant setting.
At the simple level of integration, there are virtually no shared or integrated responsibilities. The case manager may assume any of the three functions. The department of case management employs the services of a clinical case manager, a utilization manager, and a social worker. This type of integration is basically limited to the case management program housing the three departments (clinical case management, social services, and utilization management) as one — reporting to one director/administrator. Although they’re all under one department, the social worker only does social work, the nurse case manager only has clinical care responsibilities, and the utilization manager only does managed care reviews.
"Even though you may have a single department, you really don’t integrate the functions," Tahan says. "It’s almost like you have three subdepartments in one major department and reporting to one person."
On the bright side, at this low level of integration, there are few turf issues. But it is an expensive way of doing case management, "because there will continue to exist a lot of duplication and redundancy in the responsibilities among the three departments," he contends.
At the moderate level of integration, two of the three case management functions are combined: clinical case management and utilization management or clinical case management and social work/services. For example, one individual (i.e., a clinical case manager) may assume responsibility for both clinical care and social work, while someone else has sole responsibility for utilization review. Or a nurse case manager may take on utilization management responsibilities but not social work. At this level of integration, Tahan says, "You begin to maximize the effectiveness and efficiency of the case manager. The case manager is going to review the patient’s chart anyway, and the utilization reviewer/manager also is going to review the chart, so it’s only natural and easier to combine these two functions into one role. This integration results in eliminating any duplication or redundancy in the roles of the clinical case manager and the utilization reviewer. And then you leave the social worker to continue to assume social services functions and base the social worker activities on referrals from the clinical case manager."
At the complex level of integration, all three case management functions are combined into one. "So, you have one person who assumes the responsibility for managed care/utilization management, clinical case management, and also social work-type case management activities," Tahan says. At this level, some turf issues are likely to arise. This type of integration is costly to implement, at least in the beginning; however, savings will be achievable in the long run as a result of maximizing the efficiency and effectiveness of the care delivery processes and the elimination of duplication, fragmentation, and redundancy of care activities and services.
As the level of integration increases and becomes more complex, the size of the case manager’s caseload must decrease due to the complexity of the role and the increased number of activities/functions embedded in the case manager’s role. "If you want the case managers to focus on the three aspects of case management, then they cannot case manage the same number of patients as those who function in a department with level-one or simple-type integration. [Even though] in the end, and long-term-wise, you’ll be eliminating nonvalue-adding processes and saving a lot more unnecessary expenses," he adds.
At the complex level of integration, although a nurse case manager usually has primary responsibility for the three main aspects of case management, "you will continue to need the services of a social worker who may function in a consultative role to the case manager," Tahan says. "There are areas in case management where the social workers are the knowledge experts," particularly in cases involving complex discharge planning (e.g., homeless patients, those requiring placement in a skilled nursing facility, and the uninsured), and psychosocial counseling (e.g., patients who lack social support network, or are medically complex or financially compromised).
Differentiating the roles of case managers and social workers in a highly integrated case management model is a key success factor of case management programs. Clarifying the roles is essential for eliminating or reducing duplication in services. However, differentiating the roles of the case manager and social worker is not enough. Defining who will assume primary responsibility for case management is equally important. A rule of thumb is making such decision based on the patient population being case managed and its carefully examined needs and care services. Deciding who should have primary case management responsibility and who should have secondary, consultative duties must be driven by who is best to assume which case management functions, Tahan says. For example, many patients in behavioral health benefit more from social work interventions than from nursing interventions, "because social workers are better equipped to handle the counseling aspect of the care and can handle the patient’s and family’s psychosocial dynamics," he says. Because the primary issues in behavioral health are likely to be psychosocial in nature, the social worker should be the primary and the nurse the secondary case managers for this population.
In contrast, however, a geriatric population is likely to have complex medical issues (e.g., multiple medical conditions/comorbidities, chronic illnesses, and complex medical care regimen) and would more likely be better served with a nurse case manager than a social worker. Therefore, a nurse case manager should assume the primary case management responsibilities and the social worker the secondary or consultative role. "So you will know your population, you’ll study it, and then you make the decision as to who’s best to be working where," Tahan says.
There is no one rule as to who is best to assume the role of the case manager. Each organization must make its decision based on cost; clinical and administrative policies and procedures; system operations; patient population; preference of providers and their level of comfort with case management; and cost-saving and quality of care opportunities. One important issue to avoid is copying what another organization has done without carefully examining its relevance and benefit to your organization first.
[For more information, contact,
- Hussein A. Tahan, MS, DNSc(C), RN, CNA, Director of Nursing, Cardiac Specialties, Columbia Presbyterian Medical Center, New York City. Telephone: (212) 305-3888. E-mail: firstname.lastname@example.org.]