Case Management Insider

The full scope of case manager and social workers roles, functions, models, and caseloads

Help to determine maximum caseload

(Editor's note: This is a multi-part series where we will explore the most common roles, functions, models, and caseloads in the hospital case management field.)

By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY

The roles of the case manager and social worker encompass a wide range and scope of responsibilities. Over this multi-part series, we will explore the most common roles, functions, and models in the hospital case management field today. Knowing this information will drive the calculations that help to determine a maximum caseload of patients.

The most common roles assigned to case managers and social workers include the following:

  • patient flow — coordination and facilitation of care;
  • utilization and resource management;
  • denial management;
  • variance tracking;
  • transitional and discharge planning;
  • quality management;
  • psychosocial assessments and interventions.

Overriding these roles are The Case Management Society of America (CMSA 2010) Standards of Practice that apply to all roles for which a case manager or social worker might be responsible. (For information on how to get a free copy, see resource, below.) CMSA introduced the first case management standards of practice in 1995. The standards are intended to provide a foundation of the knowledge and skills that apply to the practice of case management, regardless of the case manager's practice setting or specialty. They apply whether the case manager performs some or all of the roles listed above.

Components of the standards relevant here include the definition of case management, the statement of philosophy, and the guiding principles.

Reviewing the case management literature will uncover a large number of definitions of case management. However, to standardize the specialty field of case management, an all-encompassing definition is critical. In 2009, CMSA approved and published the following definition:

"Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes."

In reviewing this definition, one can see that it applies to the field of case management in a universal manner, regardless of setting or discipline. It outlines the process as well as the outcomes that case managers are responsible for achieving on behalf of their patients or clients. It also provides the framework for the roles and functions as they are applied to specific practice settings along the continuum of care. (For information on practice settings, see list, below.)

Your hospital might have its own definition of case management. If so, still be aware of the definition as it appears in your professional organization's standards of practice. It is the foundation upon which your work sits.

Within the "Standards of Practice" is a "Statement of Philosophy." (To see the statement, go to This statement is designed to guide you in your practice and provides the framework for the guiding principles of case management practice. (To view CMSA's guiding principles, see box, below.)

Resource - Standards of Practice.

The guiding principles for case management

The Case Management Society of America (CMSA) also provides case managers with a set of guiding principles that help to guide the practice of case management. These guiding principles apply to all roles and functions within the field of case management.

The CMSA (2010) guiding principles are:

  • Use a client-centric, collaborative partnership approach.
  • Whenever possible, facilitate self-determination and self-care through the tenets of advocacy, shared decision-making, and education.
  • Use a comprehensive, holistic approach.
  • Practice cultural competence, with awareness and respect for diversity.
  • Promote the use of evidence-based care, as available.
  • Promote optimal client safety.
  • Promote the integration of behavioral change science and principles.
  • Link with community resources.
  • Assist with navigating the healthcare system to achieve successful care, for example during transitions.
  • Pursue professional excellence, and maintain competence in practice.
  • Promote quality outcomes and measurement of those outcomes.
  • Support and maintain compliance with federal, state, local, organizational, and certification rules and regulations.

What makes guiding principles unique from roles and functions is that they apply to each and every role and function and are not roles and functions themselves.

We can use patient advocacy as an example of this. Advocacy applies to each and every role and function case managers perform, regardless of setting, profession, or caseload. Guiding principles transcend all of this. If you are working on a patient's discharge plan, you will use the guiding principles of advocacy. If you are coordinating care, you will use the same principle. You will advocate for the patient during each step or function of the case management process.

Practice settings for case management

Case management practice takes place across the continuum of care, but also takes place in the payer setting, government, and employer settings as well.

The following is a list of the practice settings in which case management takes place today:

  • acute care including medical, surgical and behavioral health;
  • sub-acute medical care;
  • sub-acute rehabilitation;
  • acute rehabilitation;
  • long-term acute care;
  • skilled nursing facilities;
  • ambulatory settings including outpatient clinics and community-based organizations;
  • employer settings;
  • government insurance programs including Medicare and Medicaid;
  • third party commercial payers;
  • workers' compensation;
  • disability management;
  • independent case management companies;
  • home health;
  • hospice care;
  • physician and medical group practices;
  • disease management programs;
  • assisted living, adult day, group, and adult homes.

The role of the CM and social worker

The roles of the case manager and social worker are standard regardless of the setting in which they are practiced. Case managers and social workers might perform one, or a combination of these roles. This concept will be discussed later when models are explored.

The definition of a role is an abstract one. In the context of case management, it refers to the set of key categories that we perform. The key roles performed in case management are applied differently in different settings across the healthcare continuum, but they provide a framework for the position we have as members of the healthcare team. When we are asked what it is that we "do," we should respond with the list of roles that we perform. These higher-level categories provide the context within which we work.

Role 1: Patient flow: coordination, facilitation of care

Patient flow has to do with the management of all the patient care processes that support patients as they transition through the continuum of care. In the hospital setting, case managers perform this role through the coordination and facilitation of the patient's tests, treatments, procedures, consults, and other care interventions. The purpose of this role is to optimize each day that the patient is in the acute care setting, including evenings and weekends.

Coordination of care includes the arrangement of care interventions that the patient will require so that they occur in the proper sequence. Facilitation of care includes the interventions necessary to ensure that those care processes occur in a timely manner and without delay.

The goals of patient flow/coordination and facilitation of care:

— the plan of care is expedited and barriers to efficient throughput are identified and corrected;

— the patient is provided for in a timely manner;

— that the patient moves smoothly through the acute continuum of care;

— that each hospital day is optimized.

The management of patient flow is the principle and most important role that the hospital case manager performs. All other roles stem from this role.

Role two: Utilization, resource management

Utilization review (UR) was possibly the first role assumed by hospital case managers.

Called utilization reviewers (or UR nurses), this role included a chart review process that was performed in isolation from the rest of the interdisciplinary care team. The role was seen as an antagonistic one because the UR nurse essentially policed the chart, looking for delays in care activities that might need to be corrected. Unfortunately, because the UR nurse was not seen as a part of the team, this role often caused conflict between the UR nurse, the physician, and other care team members.

One of the first strategies in the design of acute care case management models was the incorporation of the role of utilization review into the role of the case manager. Taking this role one step further, the case manager reviews the resources applied to the patient and ensures that they are appropriate to the level of care being provided. The two fundamental functions of this process include a review of services to ensure that they are medically necessary and reasonable and that they are provided in the most appropriate setting.

Through the role of utilization management, the case manager intervenes when the care interventions do not meet the level of care being provided or when a correction to a delay in patient flow is identified. At this point, we can begin to see how the roles interface with each other. Utilization management and patient flow correlate directly with each other.

Case managers also must ensure that resources are being used appropriately in the care of their patients. This role includes the overutilization as well as the underutilization of resources applied to the direct care of patients. Among these is the use of pharmacy, radiology, and laboratory resources. Case managers must ensure that these resources are used appropriately and in a timely manner in the care of the acute patient.

Role 3: Denial management

Denial management is defined as the process of monitoring and managing the third-party payer reimbursement from pre-admission to post-discharge, including pre-authorizations, billing, and appeals management.

This role interfaces with the finance department and is most effective when the department of case management and the department of finance work collaboratively. Key functions for the case manager include ensuring that the clinical information available in the medical record is accurate and reflects the care rendered to the patient; ensuring that this information is provided, when necessary, to a third-party payer in a timely manner and based on nationally established guidelines; and ensuring that the patient is transitioned to the next level of care as quickly as possible once the patient no longer meets the clinical criteria for the current level of care.

Now we begin to see how our third role, denial management, interfaces with patient flow and utilization management. To carry out the role of denial management effectively, case managers must work closely with the precertification staff at the front end, or beginning of the process, as well as the billing staff at the back-end of the process.

When a denial cannot be avoided, the case management department might be responsible for appealing the denial received from a third-party payer. In the appeal, a case must be made for why the hospital believes that the care provided should be reimbursed. The appeals staff might complete appeals, or this function might be outsourced to a vendor.

In an era of recovery audit contractors (RACs), the appeals process is critical. Many RAC denials potentially can be overturned if the hospital has a strong appeal process in place. Of course, the best defense is always a good offense, and so the prevention of the denial in the first place is always the first goal.

Role 4: Variance tracking

Also known as avoidable days or avoidable delays, variances are defined as the causes of delays in patient throughput, care delivery, or discharge. They might not result in an increased length of stay, but they might represent delays in service and have negative affects on the quality of care.

Case managers perform the role of variance tracking while coordinating the patient's plan of care and while performing utilization management. The goals of variance tracking include the identification of important single events, undesirable variation from established levels, and patterns or trends that vary undesirably from expected outcomes.

Variance data can be collected in a spreadsheet or in a case management software program. The data should be analyzed on a monthly basis and be used to establish a foundation for quality improvement activities. As the variance is identified by the case manager, it also must be placed into a database. (For more in depth explanation of the categories, see list, below.)

Variance categories for typical CM

Categorizing the types of variances is helpful in interpreting them, cataloging them, and correcting patterns over time.

The case manager's role in this process is to work with the interdisciplinary care team to identify, manage, and correct these issues where possible. Not all variances are immediately correctable, but even the ones that are not are important to identify and collect, as the data might lead to opportunities for improvement.

At the very least, the data can help explain why a patient's stay was extended or help identify patterns or trends that might lead to other opportunities for improvement.

• Internal systems: Issues attributed to the internal delivery systems of the hospital. Examples include:

— delays in stress testing;

— telemetry bed availability;

— operating room booking delays.

• External systems: Issues attributed to the patient, either due to his or her clinical condition or other issues. Examples include:

— bed availability in a continuing care facility;

— home care service availability;

— transportation delays.

• Patient: Issues attributed to the patient, due to their clinical condition or other issues. Examples include:

— delays in decision-making;

— change in condition requiring extension of the hospital stay;

— financial issues delaying discharge.

• Family: Issues attributed to the family. Examples include:

— decision-making delays;

— lack of cooperation in discharge planning activities, such as selection of a nursing home.

• Provider: Issues associated with the providers of care to the patient. Examples include:

— errors of omission or commission;

— lack of communication;

— delays in discharge.

• Payer: Issues or delays attributed to the third-party payer. Examples include:

— authorization delays;

— delays in obtaining preferred provider services;

— delays in processing forms.

CMSA 2009 Philosophy Statement

"The underlying premise of case management is based in the fact that, when an individual reaches the optimum level of wellness and functional capability, everyone benefits: the individuals being served, their support systems, the health care delivery systems and the various reimbursement sources. Case management serves as a means for achieving client wellness and autonomy through advocacy, communication, education, identification of service resources and service facilitation ... Case management services are best offered in a climate that allows direct communication between the case manager, the client, and appropriate service personnel, in order to optimize the outcome for all concerned."

Source: Standards of Practice, 2009.