Integrated departments: Can CMs and social workers get along?

Dallas hospital uses team-building activities to reinforce collegiality

It’s no secret that at some hospitals, relations between social workers and case managers are downright chilly — if there’s any relationship at all. But turf battles and resentment are not inevitable, as long as roles are clearly defined and the right case management model is in place.

One case in point is Medical City Dallas Hospital, where Beverly Cunningham, RN, MS, director of case management, made a point of clearly delineating the roles and responsibilities of the case managers and social workers in her department.

"You really have to look at your facility, how your facility works, and what the staffing is when you’re differentiating the roles," she says. "At many hospitals, the roles aren’t differentiated, and it’s tough to say what a social worker’s responsibility is."

Monica Hale, LMSW, a social worker in Cunningham’s department, says that before Cunningham’s arrival, social workers and case managers "were performing the same roles in many ways. We were comfortable with that because as social workers, we felt that we could handle the clinical issues and complications."

Although change took some getting used to, it was worth it, Hale says. "It ended up with having RN case managers be true to their profession and allowing social workers to do what we do best — working with the families, providing supportive counseling, and looking at the big picture to find resources and things like that. It has been a challenge, but I’ve been glad that we’ve had the opportunity to explore our true professional roles."

In Cunningham’s model, the nurse case manager often is the "triage person, who will let the social worker know that there is a need." Regardless of the model used, however, what’s most important is that some sort of differentiation is made.

"Whether you say that the nurses are going to do discharge planning, the social workers are going to do counseling and handle complex placement issues, or whatever it is, it’s important that you really do differentiate it and everybody knows what the roles are," Cunningham says. 

It’s also important for those differences to be reflected in the job descriptions. At Medical City, Cunningham rewrote the job descriptions of RN case managers and social workers to specify their different responsibilities.

"In the job description, at our hospital, we identify what makes a solid performer and then what makes somebody exemplary," she says. 

Of course, changes can’t just be made on paper; they must be reflected in the daily practice of the department. And that means securing the cooperation of the RN case managers and social workers.

Cunningham explains that because she was new as director, changing the model was a fairly easy process. "When I came here, I had individual meetings with all of my staff. I said, Tell me what it is you’re doing. What are your roles and responsibilities?’ That’s where I picked up that people were doing a lot of the same things."

Hale acknowledges that when Cunningham first arrived, they were "a little nervous and not sure how this was going to work." The social workers, in particular, had concerns. "Working in a group where we’re outnumbered significantly by RN case managers and getting a new director who is an RN, I think we would always have the concern, Is she going to get rid of us?’"

Those initial concerns were dispelled quickly, however. "She made it very clear from the beginning that it’s a team that needs both professions, that we were both valued for different professional roles," Hale says. "She made us feel like we were all significant parts of this team and very much needed. We’re just fortunate that our group here has been responsive to that and feels the same."

Hale says that without Cunningham’s positive attitude and approach, "it could have been a very negative change. It could have been far more difficult. But the tone she set was that this was something that would help us grow in our profession."

Unfortunately, at some hospitals, change is more difficult, especially when RN case managers and social workers have a history of territorial disputes.

It’s important to have social work and case management in the same department, Cunningham says. Having both groups under the same leadership can help foster a common sense of identity. Also, whether the director of the department is a social worker or an RN, "it’s important that director be sensitive to the profession that they are not [a member of]." She adds that, if there is an RN director of case management and the department includes social work, there should be a social worker who directly supervises social workers.

One technique that has helped head off any territorialism has been the use of teams that include both social workers and RN case managers. These include a women’s and children’s team that is responsible for the children’s hospital and women’s services, a medical/surgical team, and an ortho/neuro rehabilitation team.

"When I have to do my business plan, they have to write their business plan of what their focus is," Cunningham says. "It’s not the nurse case manager’s business plan or the social worker’s business plan. It is: Together, what are we going to accomplish?"

Related to that, Cunningham makes sure that nurses and social workers in the department share a feeling of responsibility for case management outcomes.

"We look at length of stay as everybody’s responsibility," she says. "I look at avoidable days as everybody’s responsibility. When we see that we have shared outcomes, that tends to move us out of that territorialism."

Another way to develop a sense of collegiality among nurse case managers and social workers within a department is to engage in some old-fashioned team-building exercises.

For example, at Medical City, at least once a quarter, members of the case management department have some type of outing. This summer, they went to the local farmers’ market together. They’ve also gone as a group to the Texas State Fair. Staff who chose not to go were allowed to leave work a half-day early.

Cunningham acknowledges that some facilities might not have the flexibility to have such outings, but "you have to think of things you can do within your department that bring the group together. I feel like that’s my responsibility," she explains.

One way to help bring nurse case managers and social workers together is to have shared continuing education (CE). At Medical City, the department has two sessions per month, "and we like it if they can be CEs for social workers and for nurses," Cunningham says. Often, however, nurses will attend even if the session is just for social workers.

Hale adds that while there is a clear difference in their professional roles, all are treated equally.

[For more information, contact:

  • Beverly Cunningham, RN, BSN, MS, Director of Case Management, Medical City Dallas Hospital. Telephone: (972) 566-7000.

Cunningham and Hale will conduct a presentation, "The Best of Both Worlds: Nurse Case Manager and Social Worker Collaboration" at the 2003 Hospital Case Management Conference, to be held April 27-29 in Atlanta. For more information about the conference or to register, call (800) 688-2421.]