By Elaine Christie, Author

As healthcare delivery evolved over the decades, case management departments have emerged as leaders in managing discharge planning and lowering readmission rates.

However, one ongoing area of confusion is the division between the RN case manager and the social worker case manager.

The key difference is that social workers handle psychosocial support along with discharge planning. While a social worker can work as a case manager, he or she is not an RN case manager, who has a different education, mandatory licensure, and a more clinical focus.

“There’s this notion that we’re all homogenized. My message is that we have different licenses and knowledge and we need to optimize those differences, not blend them together,” says Toni Cesta, PhD, RN, FAAN, partner and consultant at Oklahoma-based Case Management Concepts.

“We go into many hospitals where social workers only do discharge planning or they only do psychosocial assessments,” Cesta says. “Those are two ends of the extreme; the best approach is someplace in the middle of the two.”

Discharge planning should be shared between social workers and case managers. It follows the same principles and functions as transitional planning with one exception: It involves the process of assessing the patient’s needs after he or she leaves the acute care setting.

Cesta uses the example of RN case managers and social worker case managers sitting around a table at a morning meeting with 10 new admissions.

“There must be a screening of what the patient truly needs so the appropriate discipline can be applied. If they simply divide the work, it negates the differences that each person brings to the team,” she says.

She recommends the dyad model, where upon admission, every patient is assessed by an RN case manager and screened for potential social work needs. This 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.

Understanding Psychosocial Needs

When social workers were the main drivers of discharge planning 30 years ago, it was much less complicated; patients usually either went home or to a nursing home. In other words, there wasn’t much discussion needed by the patient’s care team.

“There’s a lack of understanding, and a perception that social workers are all about discharge planning. They have so much more to bring to the table,” Cesta says.

If processes aren’t hardwired and roles aren’t delineated, Cesta says, there’s a real possibility that some patients will get through the course of a hospital stay and fall through the cracks.

Because of that worry, psychosocial referrals to social worker case managers should be a standardized process, Cesta recommends, almost like an algorithm. For every admission, every patient should be seen. The majority of times the case manager will see that patient on assessment, using the minimum data set to formulate the initial discharge plan and at the same time refer to the social worker. (For more information, see related story in this issue.)

Every patient is assigned a nurse case manager who will handle utilization review, denial management, etc., and a subset also will have a social worker. Approximately 30% of hospitalized inpatients will meet the psychosocial referral criteria, according to Cesta.

Which types of patients will meet that psychosocial criteria? A medically complex, high-risk patient could be referred to a social worker for a variety of psychosocial reasons, including the following:

• adjustment to illness or difficulty coping;

• major illness causing lifestyle change;

• behavior management problems;

• new or poor prognosis;

• end stage of illness;

• family concerns and/or conflicts;

• cultural and/or language issues;

• inadequate social and/or financial support;

• nonadherence issues;

• ethical concerns;

• abuse and/or neglect of elder, adult, or child;

• multisystem trauma;

• psychiatric and/or substance abuse issues affecting current hospitalization;

• homelessness affecting current hospitalization or request for housing;

• patient/family considering long-term care placement, assisted living, or adult home.