Initiatives from CMS make it more important for case management leadership to review the duties, roles, and responsibilities of all disciplines and build an effective model, says Patrick Hernandez, DBH, MSW, LMSW, CPRP, management consultant for Berkeley Research Group.
Hernandez recommends that case management departments become organized by adopting either the dyad model or the triad model of case management. The triad model has three separate and distinct roles: RN case managers, social workers, and utilization review nurses.
“Some hospitals use the dyad model, which assigns care coordination, discharge planning, and utilization review to case managers, and psychosocial issues to the social worker. This model works well if the ratio of case manager to patients is low and the case manager is highly skilled,” he says.
When departments don’t use a dedicated model, the lines are blurred — resulting in gaps in care or duplication of effort, he says.
“Whatever the model a case management department uses, the best practice requires each discipline to stay in their ‘swim lane’ and work to the height of their respective licenses. This creates a smooth, efficient work flow,” he adds.
Medical City Dallas Hospital uses the triad model with separate RN utilization nurses who are responsible for ensuring that patients are in the right status, dealing with approvals and denials from payers, and handling other reimbursement-related tasks, says Beth Griffin, LCSW, manager of case management.
“RN case managers are the ones who drive the boat. They are in charge of care coordination and making sure patients get what they need from admission to discharge,” she says. The case managers complete an admission assessment within 48 hours of admission.
If the patient needs to go to a skilled nursing facility, a long-term acute care hospital (LTACH), or hospice, social workers receive a referral. They also are called on when patients are homeless, or if there are signs of abuse and neglect.
“Social workers handle the more socially complex cases, such as dealing with adult protective services and child protective services, or bereavement,” she says.
The RN case managers should be responsible for patient flow, utilization management, and the clinical components of discharge planning, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.
Social workers should be responsible for psychosocial counseling and support, and discharge planning activities that are psychosocially integrated, she says.
For instance, an RN case manager should be responsible for discharge planning for a patient who will receive nursing services in the home. A social worker should handle hospice placement, long-term nursing home placement, and other discharge where there is a need for psychosocial support, she says.
In the average hospital, about 30% of patients need a social work intervention, Cesta says.
An effective way to optimize care coordination and discharge planning is to have social workers and case managers work together as a team, says Vivian Campagna, RN-BC, MSN, CCM, chief industry relations officer for the Commission for Case Management Certification.
She suggests that a team of one nurse case manager and one social worker collaborate closely and divide the workload depending on patients’ needs. Those needs should determine which discipline will serve as team leader for each patient, she adds.
Case managers should be assigned by unit and by team, and the number of staff depends on the unit. The teams should meet every day and determine patient needs, then divide the work based on the complexity and the level of expertise needed, Cesta says.
Case manager and social worker caseloads and ratios should not be based on how many beds are in a unit, but on the needs of the patients, Campagna adds. “Organizations need to look at their population, what types of patients they treat, and what patients need,” she says.
Peggy Rossi, BSN, MPA, CCM, ACMC-RN, CMAC, an independent case management consultant, recommends that case managers handle all of the discharge planning for patients to avoid confusion when the responsibility is shared. “It can be very frustrating when discharge plans are handled piecemeal, with the social worker handling the nursing home placement and the nurse setting up home health. It’s confusing to the patient and to the staff,” she says.
With some patients, it may be necessary to develop two discharge plans at the same time, Rossi points out. For example, a patient may want to go home but the physician thinks the patient may need a skilled nursing stay. The discharge planner must cover both contingencies.
“If the case manager and social worker divide the work, there may be two people talking to the patient about different plans at different times, which creates a lot of confusion,” she says.
There are some aspects of case management that both social workers and nurse case managers can do very well, Campagna says. For example, each can complete a patient assessment that includes both clinical and psychosocial elements, she says.
“RN case managers have the expertise to coordinate patient care, but they should collaborate with their social work colleagues to see the bigger picture,” she says.
Case managers and social workers each can evaluate a plan, but they look at it from different perspectives, Campagna says.
“Each can make a plan and understand what patients may need when they leave the hospital, but the nurse has the skills to arrange clinical services and the social worker has the knowledge of support in the community,” she says.
Rather than cross-training case managers and social workers to perform the same tasks, Campagna recommends educating the staff on the nuances of each role so they will know when they need to consult the other discipline.
“One of the keys to good case management is to recognize when more information is needed,” she says.