Case Management Insider

Continuing analysis into the roles, functions, models, and caseloads of case management

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

In the December 2011 issue of Case Management Insider we discussed the roles most commonly used by case managers in today's acute care setting. These included 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.

In this issue we will continue our discussion by reviewing the functions performed under each of the roles listed above. Functions are defined as the series of activities or tasks that are conducted within each role. They are the specific actions taken by a case manager in the performance of their roles. While the functions might vary from hospital to hospital and model to model, the fundamental roles of the case manager stay the same.

Coordination and facilitation of care

Patient flow involves the coordination of the patient's care needs and interventions as well as the facilitation of those interventions. To manage resource utilization and length of stay, the hospital case manager must perform several functions aimed at ensuring that the patient care processes are moving along smoothly and outcomes are being achieved.

The key functions applied to this role include:

  • assessing every patient on admission;
  • reassessing patients daily;
  • leading and/or attending daily interdisciplinary care rounds;
  • creating a plan of care that outlines the key interventions and outcomes to be achieved each day of the inpatient stay;
  • coordinating the key interventions among and between the members of the interdisciplinary team;
  • coordinating as needed with the family and/or family caregiver(s);
  • identifying delays in patient care processes and intervene to correct them.

Case managers in the hospital setting must consider what care interventions the patient will need while the patient is in the hospital, as well as what they will need as they transition beyond the walls of the hospital. They must identify these needs and then coordinate and facilitate them. Patient care rounds are one of the tools used to gather relevant information that is useful in the care planning process. A patient care assessment on admission and throughout the stay is another important tool for staying current with the patient's plan of care and ongoing needs. Most importantly, barriers to achieving the appropriate interventions and outcomes must be identified by the case manager and these delays or barriers must be removed as necessary. This will be discussed in more detail later.

Patient flow is one of the most fundamental and necessary roles of the hospital case manager. It is the foundation from which all the other roles emanate. If done properly, the plan of care will be expedited and the patient will move smoothly through the continuum of care.

Utilization and resource management

In the role of utilization and resource management, the case manager must perform several functions. The first of these is the supervision of resources. This includes monitoring both the over-utilization as well as under-utilization of resources associated with the care of the patient. Resources include the products we use to treat patients, those we use to diagnosis patients, as well as the labor associated with the use of the product resources. When patients are over-treated, this absorbs product and personnel resources. When patients are under-treated, it can have a negative affect on the quality of care.

Another function performed in the role of utilization and resource management is determining the appropriateness of the admission, as well as the continued stay of the patient in the hospital. This function is typically performed using a national set of clinical criteria that provides objective clinical markers that the case manager must use to determine whether the patient needs to be in the hospital. This determination is made prior to or at the point of admission and then must be repeated throughout the hospitalization.

This function is critical in the management of resources as well as the management of length of stay. It helps to inform the case manager as to when the patient is clinically ready to transition to the next level of care. The next level of care might include transitioning from critical care to a general medical floor, or off telemetry, or out of the hospital.

In the role of utilization management, the function of utilization review is also included. This function includes reviewing the patient's status, as per above, and then relaying this information to a third party payer for admission or continued stay determination. It is the front-end process of denial management. (For more information on denial management, see story, below.) However, these reviews should always be done regardless of payer, as they are important to management of resources and length of stay. The roles and functions that have been discussed in this month's and last month's issues need to be taken into consideration when developing a case management model for a specific hospital or health system. In next month's issue, we will explore the ways in which these roles and functions can be combined into several examples of best practice models.

The monitoring process of denial management

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

Denial management is the process of monitoring and managing reimbursement from a third party payer. It includes the following activities, some of which are performed by case management, and some that are performed by patient accounting in the finance department. They include:

  • pre-authorization — finance;
  • concurrent review — case management;
  • billing — finance;
  • appeals — case management and finance.

In the role of denial management the case manager must perform the following key functions:

  • Ensure that the clinical information available in the medical record is accurate and reflects the care rendered to the patient.
  • Ensure that this information is provided, when necessary, to a third party payer in a timely manner and based on nationally established guidelines.
  • Ensure 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.
  • Appeal any clinically related third party denials that the hospital feels meet an in-patient level of care based on national clinical guidelines.

The case management staff must work closely with the pre-certification staff at the front end and the billing office at the back end. Case managers are the link between these processes, ultimately responsible for ensuring that a denial of payment is avoided whenever possible.

Variance tracking and avoidable delays

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

Variances, which are also referred to as avoidable days or avoidable delays, are any events or issues that affect quality of care, length of stay, or throughput. In this role, case mangers are responsible for performing several functions aimed at identifying and correcting barriers to efficient and effective care delivery.

In this role, the case manager performs several functions. The first involves the identification of delays in throughput. The case manager will look for indicators of any delays that are caused by one of six categories of issues:

Internal systems: issues attributed to the internal delivery systems of the hospital.

— delays in MRI;

— delays in physical therapy;

— operating booking delays.

External systems: issues attributed to outside resources and services.

— specialty bed availability in the community;

— home care service availability;

— transportation delays.

Patient issues: issues attributed to the patient, either due to his or her clinical condition or other issues such as:

— delays in decision-making;

— changes in clinical status requiring extension of the hospital stay;

— financial issues delaying discharge.

Family issues: issues attributed to the family such as:

— lack of cooperation in discharge planning activities;

— inability to care for patient at home;

— delays in decision-making.

Provider issues: issues associated with the providers of care to the patient, including:

— lack of communication;

— delays in treatment;

— delays in discharge.

Payer issues: issues or delays attributed to the third party payer such as:

— delays in responding to request for authorization;

— delays in processing forms;

— delays in identifying preferred provider.

Once the issue has been identified, the case manager must then intervene to correct the delay when possible. Corrective actions should be taken at the point of service whenever possible so that the issue has the smallest impact on the patient's care as possible. In order to correct the problem, the case manager might have to engage other departments or disciplines in the process. If there is a question as to how to correct the problem, and/or the case manager is not sure how to correct the problem, he or she should always discuss the issue with the immediate supervisor. In some instances the issue might need to be brought to a higher level for intervention and corrective action.

The last function is to catalogue the delays into a database. The delay would be identified first by the issue, then the responsible party. Finally, the case manager would determine that each occurrence caused a delay of a certain amount of time.

For example, the case manager identifies a delay in a patient receiving an MRI. The case manager would first have to determine the responsible party for the MRI delay. If the radiology department caused the delay due to their scheduling and availability, then the responsible party would be "internal system." If the delays lasted for one day, then it would be counted as one occurrence lasting one day.

Transitional and discharge planning

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

The role of transitional and discharge planning is focused on the movement of the patient through the acute care continuum, and to the next level of care. The next level of care might be a higher or a lower level.

Both are defined as "a collaborative, interdisciplinary process of assessment, planning, implementation and evaluation of the patient's healthcare needs following the current phase of illness."1

The case manager plays a part in transitional and discharge planning. Transitional planning is the process that case managers apply, to ensure that appropriate resources and services are provided to patients and that these services are provided in the most appropriate setting or level of care. Transitional planning dovetails with patient flow and utilization management.

As the case manager reviews the patient's clinical criteria as it relates to the patient's level of care, the case manager is also identifying the point at which the patient is ready to transition to the next level. Any delays in achieving the outcomes are corrected during the process of coordination and facilitation of care. Finally, the patient is ready to move, and the case manager now ensures that the transition takes place as smoothly and efficiently as possible.

Discharge planning follows the same principles as transitional planning, but with one exception. It focuses on the movement of the patient from the acute care setting to a lower level of care. It involves the process of assessing the patient's needs after discharge from a healthcare facility, and ensuring that the necessary services are in place for the patient before leaving the acute care setting.

This process ensures that the patient's discharge is timely, appropriate, and safe, incorporating the best use of resources that the patient may need in the community.

Example of integration of the roles

The case manager identifies that the patient meets the clinical criteria to be taken off telemetry (utilization management). The case manager works with the physician to communicate this and to obtain the order to discontinue to telemetry. The discontinuation order means that the patient may now be moved to another unit or bed (denial management). The case manager, working with the bed assignment staff, facilitates the process, thereby ensuring that the patient moves as quickly as possible with minimal delays to the process (transitional planning). By accomplishing this, the case manager is also ensuring that the telemetry bed is now available for the next patient who needs that service (patient flow). If the physician does not agree with the case manager and telemetry is not discontinued, then the case manager can identify this issue as a variance (variance tracking).


  1. Cesta TG, Tahan HA. The Case Manager's Survival Guide: Winning Strategies for Clinical Practice. St. Louis: Mosby; 2002.

Quality management for case managers

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

The role of quality management for case managers means that they are participating in a process that ensures the patient care is delivered at or above quality standards as set forth by the hospital, regulatory bodies, and national guidelines.

Case managers participate in this process with all members of the interdisciplinary team. The specific functions might include the following:

  • identification and documentation of adverse events;
  • documentation of readmissions;
  • management of progression toward expected outcomes of care;
  • concurrent core measure review.

Not all case managers perform all of these functions. At the least, the case manager can work to ensure that a minimum level of quality is maintained at all times for their patients. If these functions are not a primary role for the case manager they can, at the least, be a collaborative member in the quality of care process.

Core measures may be a function that falls under the responsibility of the case manager. Core measures encompass the data that are reported to regulatory bodies as part of their quality management strategies.

Psychosocial assessment and counseling

An assessment of the patient's psychosocial condition will drive their ability to cope with their current phase of illness or chronic condition. It also will impact the discharge planning process and the ultimate discharge destination. A psychosocial assessment can be performed by the case manager or the social worker. If performed by the case manager, a referral can be made to the social worker as needed.

Psychosocial interventions might be particularly important for family members of patients who are in the emergency department or critical care areas such as the neonatal intensive care unit, the medical or surgical intensive care units, the burn units, or trauma units. These families might be under tremendous stress and might need counseling or psychosocial support. Psychosocial counseling and other interventions might need to be continued once the patient leaves the hospital. Psychosocial interventions relate directly to discharge planning, patient outcomes, quality of care, and utilization management.

Whichever discipline performs the psychosocial intervention depends on the case management model and how the roles and functions are delegated. In any case, an assessment of the patient's psychosocial status needs to be performed as part of a comprehensive discharge planning assessment. Included in their assessment must be an assessment of the family/significant other/support systems to determine the best discharge plan for the patient.

This role is typical owned by social work, as the discipline of social work is best prepared to assess and manage issues related to the family, social systems and crisis.