New jobs with titles like care manager, care coordinator, navigator, patient progression nurse, and transition coordinator are popping up in various settings including hospitals, home health agencies, post-acute facilities, insurance companies, or community organizations.

The titles and the job descriptions may vary, but they’re all doing something that involves care coordination, says Karen Zander, RN, MS, CMAC, FAAN, president and chief executive officer for The Center for Case Management.

The problem is that in many instances, nobody knows who is in charge, she adds.

“Hospital leadership needs to look at everything that is being done for patients and determine who is really responsible and accountable for each task. There needs to be an agreement about who is the person in charge,” Zander says.

She recommends that whoever is directly involved with the patient at the time be the person in charge. “When patients are in a particular setting, the case manager in this setting has the most control at the time,” she says.

Healthcare providers in every setting need to create a new, overarching role that belongs to the organization at large and is a touchpoint for all of the care coordination services, suggests Donna Hopkins, MS, RN, CMAC, vice president at Novia Strategies, a national healthcare consulting firm. She recommends staffing the new role with a higher-level case manager or social worker who is the point person for care coordinators throughout the continuum in an organization where risk is assumed.

In some parts of the country, the clinical nurse leader role fills the need for coordination across various settings, Hopkins says. (For more on the clinical nurse leader role, see related article in this issue.)

The proliferation of case managers in various settings makes it essential to have a lead case manager who can make sure everybody is on the same page and to give patients one person to contact, says Vivian Campagna, RN-BC, MSN, CCM, chief industry relations officer for the Commission for Case Management Certification.

The person who is in charge of orchestrating all the care coordination efforts depends on the setting and the protocol for that organization, Campagna says. “But there should be a case manager in the lead position and whenever possible, the patient should have one person to contact,” she says.

A case manager who has achieved certification is ideal for the role, Campagna says. “The certification process validates a case manager’s capabilities, skills, and knowledge,” she adds.

Case management leadership should ensure that care is integrated and that the team’s roles are defined so there won’t be duplication, Campagna says.

Campagna suggests a model similar to one used by the Veterans Health Administration system to coordinate the efforts of everyone in the continuum and to ensure care coordinators at all levels of care are on the same page.

“The VA has care coordinators in primary care, mental health, women’s programs, homeless groups, and many other programs, but they also have a care review team headed by a designated lead care manager who is coordinating all of the care coordinators in the various programs and making sure that the patient has one point of contact,” she says.

The lead case manager coordinates everyone who is working with the patient regardless of the setting, Campagna says.

“The lead case manager knows the patient’s story, keeps everyone who is working with the patient apprised of what is going on, and communicates with case managers who are taking over when the patient moves between providers to make sure they understand what they need to know about the patient,” she says.

It could be the case management supervisor who oversees the handoff when patients are transferred from one unit to another, or it could be a case manager from a community program who followed the patient into the hospital.

“There should be one person who is able to manage the care across all settings,” she says.

Zander recommends conducting a process improvement project to identify instances of fragmentation and redundancy among the various care coordination efforts of the organization.

She suggests using a responsibility assignment matrix, such as the RACI (Responsible, Accountable, Consulted, Informed) tool to lay out the roles and responsibilities of everyone on the team. (For more information on the RACI chart, visit:

Start by listing the team members across the top of the page. On the side of the page, list the various tasks that must be performed for all inpatients, such as “Develop Discharge Plan,” “Conduct Medication Reconciliation,” and others. Review each task and indicate on the chart which discipline is responsible for performing the work, which is ultimately accountable for completion, who should be consulted before the work is completed or the decision made, and who should be informed about what was performed.

Look for duplications or tasks that aren’t being handled.

“If everybody knows their responsibilities and those of the rest of the team, it eliminates duplication, missed work, and tasks that need to be redone,” she says.