With increasingly complex patients and changing reimbursement rules, it takes both an RN case manager and a social worker to gather a complete picture of a patient’s situation and create an effective discharge plan.

• Case management leadership should assign different duties to each discipline to take advantage of their unique skills and allow both disciplines to work at the top of their licenses.

• Create a clear, concise job description for each discipline and formal policies and procedures that make clear the roles and responsibilities of each.

• Creating a formal model helps avoid confusion and duplication, and ends confusion about who does what.

• The case manager-social worker team should be compatible and work well together.

As the Centers for Medicare & Medicaid Services (CMS) moves toward basing reimbursement on outcomes, it’s going to take both an RN case manager and a social worker to understand the complete picture of a patient’s situation and to work together on a discharge plan that includes everything the patient needs to avoid a readmission or an ED visit.

In today’s world, many patients have such complex needs that each discipline should consult with others to ensure that all needs are met, says Vivian Campagna, RN-BC, MSN, CCM, chief industry relations officer for the Commission for Case Management Certification. That’s why in a growing number of hospitals, case managers and social workers act as a team and divide the responsibilities for their patients, she adds.

“Social workers and RN case managers have different training, different skills, and see patients from a different perspective. When the two disciplines collaborate, they provide a 360-degree assessment of the patient, which results in a good plan that addresses all of the patient’s issues,” she says.

But in some organizations, social workers and RN case managers are asked to do the same thing, even though they have different skill sets, adds Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

In other organizations, the social workers and case managers report to separate leaders. “This makes it difficult to achieve a collaborative, integrated model, which is the best practice,” Cesta says. It also creates confusion about the role that social workers play on the interdisciplinary team and what case managers do, she adds.

Part of the reason that the roles are blurred may be that hospital administrators don’t understand the unique qualifications of each discipline, says Peggy Rossi, BSN, MPA, CCM, ACMC-RN, CMAC, an independent case management consultant.

Case management leadership must educate the hospital’s executive team on the difference between social workers and RN case managers and the benefits of them working as a team, Rossi says.

“In some hospitals, the leadership has hired licensed staff in order to comply with Medicare Conditions of Participation, but they don’t make the best use of their skills. For instance, I’ve been in hospitals where the only job a master’s-prepared social worker does is nursing home placement,” she says.

Case management leadership should create a department that maximizes the skills of each discipline so each staff member can work at the top of his or her license, Cesta adds.

“This requires a clear understanding of what each discipline is responsible for in the case management department, how they complement each other, and collaborate with each other,” she says.

Unfortunately, that doesn’t always happen, says Patrick Hernandez, DBH, MSW, LMSW, CPRP, management consultant for Berkeley Research Group.

Hernandez, who consults with hospitals across the country, says he has encountered case management departments “patched together, either through changing CMS requirements or in an attempt to meet new regulatory standards.”

Some hospitals fail to develop well-structured case management departments. “Instead, they [hire] nurses or social workers to help them comply with the ever-changing rules from Medicare. The staff is operating well and meeting the needs of patients, but this can be misleading. Often times, there are no clearly defined responsibilities between RN case managers and social workers. This can often confuse patients and their families,” he says.

Many case management departments developed their present structures as hospitals adjusted to new CMS initiatives, Hernandez adds. “Once CMS moved toward value-based care, it forced healthcare systems to re-evaluate the way they approach patient care from admission to the inpatient setting and well into post-acute care. Hospitals could no longer just ‘treat and release.’ Hospitals had to take qualitative steps in discharge planning to avoid higher rates of readmissions. Often, case management departments played an important role in these healthcare solutions,” he says.

The struggle to build a case management department to succeed in today’s healthcare environment continues, he says. Finding balance between keeping length-of-stay and readmission rates low has been challenging for many hospitals. If patients are discharged too quickly, they are likely to be readmitted; if they stay too long, it can be financially disastrous for hospitals, he says. “Invariably, these are hospitals with case management departments that were created without a lot of thought and where the roles of each discipline are not clear,” he adds.

It’s not too late for case management leadership to reorganize and create an effective department, Cesta adds. The first step is for the leadership to develop a detailed document that delineates each discipline’s role and function.

“In some hospitals, neither discipline understands what the other one is doing. This creates angst between the two disciplines,” Cesta says. “Social workers may feel threatened if they feel that the RN case managers are trying to take over their jobs, and vice versa. This is why it’s so important to define each role in detail.” (For more details on dividing the workload, see related article in this issue.)

In many settings, physicians, nurses, and other staff don’t understand the distinctions between the skills of nurses and those of social workers, Campagna says.

“Everyone on the team should understand what each member brings to the table that is different from what the others are doing,” she says.

Medical City Dallas Hospital’s case management department provides ongoing education to help the nursing staff understand the difference between social work and case management, says Beth Griffin, LCSW, manager of case management. “There is a lot of communication between all of the disciplines. It’s the only way to create a cohesive team,” she says.

The case managers and social workers attend interdisciplinary rounds every day and meet with other team members as needed throughout the day. “It’s all about working together as a team to be more proactive,” Griffin says.

The staff are cross-trained to help each other. When one team member is absent, there is a back-up person in the same discipline to help with his or her duties.

“We want to make sure that no one is trying to do things that aren’t within their scope of practice,” she says.

In some hospitals, social workers are being asked to assume more case management duties to handle the increasing case management workload as CMS and other payers enact more rules, Hernandez reports. Assigning social workers duties that typically are handled by registered nurses is setting them up for potential failure, he adds.

“Social workers don’t have the clinical education and experience to do the same jobs as RNs. They are not trained medically. While it is possible that social workers could learn the general medical components while they are on the job, they may not know all of the details they need to handle tasks that are better suited to RNs,” he says.

When social workers are asked to perform a task that is better suited to a nurse, it impedes efficiency and patient throughput, and it may affect patient outcomes, he adds.

For instance, he says, there is a short window of time for appropriate patients to transfer to a long-term acute care hospital (LTACH) and patients must meet certain criteria. Nurses would know the medical criteria, but a social worker would not and should not be expected to since it is outside of his or her license and practice. If the three-day opportunity is missed, the patient’s length of stay in the acute care hospital could be extended.

Hernandez urges hospital leadership to allow social workers to use their unique skills. “They are in the hospital, on the floor, trained and ready to help patients. It behooves hospitals to utilize this great resource,” he says.

Licensed clinical social workers have the skills to provide counseling for families facing end-of-life issues, handle spousal or elder abuse problems, link the family with community resources such as medication assistance or transportation services, find shelter for homeless patients, and handle other psychosocial issues, Rossi says.

“In today’s world where there are so many patients with complex medical problems as well as patients with substance abuse issues, social workers should be in a role where they work in collaboration with case managers and the nursing staff to manage all of the patient’s needs,” she adds.

An increasing number of patients suffer from behavioral health issues, Hernandez points out.

“Opioid use is rocketing. About 20% of patients that come into the hospital have mental health issues, and 60% to 70% of those have a chronic condition. You can’t separate the two. It’s counterproductive to treat a patient’s chronic illness and hope they feel better emotionally,” he says.

Being aware of and working to overcome the social determinants of health is a critical part of ensuring the success of the discharge plan, and that’s where social workers are invaluable, Campagna says.

“If patients don’t have food, don’t feel safe at home, and/or lack transportation, you can’t expect good outcomes after discharge. This makes social workers an integral part of the case management and discharge planning process,” she says.

Social workers are familiar with the community and the available services, Campagna points out. Social workers are advocates by training and can play a vital part on the care transition team, she adds.

More often than not, patients with clinically complex conditions also have psychosocial needs, Campagna points out.

“The nurse/social worker case management team should work collaboratively to address each patient need with each discipline, bringing their very distinct skill set to the table,” she says.

Case managers and social workers should huddle several times a day to make sure each is doing what needs to be done and that the needs of all patients are being served, Rossi recommends.

“Multidisciplinary rounds are critical. The nurses on the floor, the case manager, and the social worker on the unit should meet at least once a day and go over all the patients and what’s happening with them to make sure everything is being handled and there are no duplications,” she says.

“If the case managers and social workers are not working together, patients won’t get everything they need for a safe discharge and will be readmitted,” Rossi says.

The treatment team can treat the physical issues while patients are in the hospital, but if patients don’t have a safe place to go, can’t pay for their medication, or aren’t capable of living on their own, the hospital will wind up getting them back, Campagna points out.

“If social workers and case managers collaborate and everybody does what they do best, you have the ability not only to reach optimal outcomes while the patient is in the hospital, but to ensure that the good outcomes continue when the patient goes back to the community,” she says.