By Toni Cesta, PhD, RN, FAAN


It is well understood that contemporary case management includes a number of roles and functions for the RN case manager and social worker. These roles typically include coordination and facilitation of care, utilization management, discharge planning, denial management, avoidable day management, and some aspects of quality management. This month, we will turn our attention to coordination and facilitation of care, which is an important — yet sometimes overlooked — role of the case manager and social worker.

What Is Coordination of Care?

There are a wide variety of definitions of coordination of care. In fact, recent literature indicates that there are at least 40 such definitions. For the purposes of discussion of the relationship between care coordination and case management, let’s consider the following definition from the Agency for Healthcare Research and Quality:

“Care coordination is the deliberate organization of patient care activities between two or more participants, including the patient, involved in a patient’s care used to facilitate the appropriate delivery of health services.” (This definition can be found at:

The organization or coordination of care, often performed by the RN case manager, is the appropriation of personnel and other resources needed to perform and complete necessary patient care activities. It includes the exchange of information among team members as well as the brokering of services on behalf of the patient and family. While care coordination is a team effort like all efforts in patient care, someone must lead the team around this activity. It is a widely supported concept that the case manager is best positioned to lead this activity because the case manager performs care coordination as one of his or her primary roles. In the implementation of this role, the case manager integrates utilization management and discharge planning activities in the process. All these roles interface with each other as the patient moves toward discharge.

The Impact of Poor Care Coordination

As care coordinators, case managers address and correct potential gaps in clinical care delivery. Therefore, we must have a credible level of clinical knowledge with which to perform this role. When failures in care coordination occur, quality of care can be adversely affected. Examples of these types of failures would include lack of handoff communication, delays in service delivery, and over- or underuse of healthcare resources.

In addition to the negative effect on quality of care, lack of adequate care coordination also can result in increased healthcare costs. These costs can be incurred through increased length of stay, increased and/or unnecessary use of resources, returns to the ED, or readmissions to the hospital.

Ultimately, the primary goal of care coordination is to ensure that the patient receives the delivery of the highest-quality, highest-value healthcare services possible. The greater the fragmentation in care, the greater the need for care coordination. A particular focus of care coordination along the continuum of care is coordination of resources and services provided by a healthcare organization to meet the ongoing identified needs of its patients. This includes referrals to appropriate community resources and liaising with others, such as the individual patient’s physician or primary care provider, other healthcare organizations, and community services involved in care or services.

Care coordination processes also can be affected by more highly clinically complex patients, psychosocial complexities, and the ability and capacity of the patient to manage his or her own care processes. For these reasons, highly complex patients should always have a case manager at the helm of their care delivery teams.

Care Coordination and The Joint Commission

The Joint Commission (TJC) has greatly influenced healthcare organizations’ view of and focus on the continuum of care and services in its accreditation standards. According to TJC, case management services must aim at coordinating care and services across the continuum of care. This is necessary especially because patients may need a range of services in multiple settings and from multiple healthcare providers. This standard makes it essential for hospitals to view the care they provide to patients as part of an integrated system of settings, services, healthcare providers, and care levels. These characteristics comprise the continuum of care. Therefore, it is in the best interest of hospitals to ensure that they have a process in place that addresses compliance with the continuum of care standard described by TJC. This is the transitional planning process and must be applied for all patients and at every encounter. It is best ensured if case managers assume the responsibility for transitional planning, especially because they are better prepared for this function compared with other providers.

The Joint Commission defines the continuum of care, focusing on the role healthcare organizations play in coordination and transitions of care. The continuum of care, according to TJC, includes care provided over time in various settings, programs, or services and spanning the illness-to-wellness continuum. Case management programs and delivery models enhance compliance with the provision of care standard, which also includes expectations about the care coordination continuum and transitions of care. These standards naturally focus on care coordination and transitions of care activities that delineate standards in terms of the process of patients’ admission, discharge, and transfer or transition to another care setting from a hospital. These activities are essential components of the role of the case manager and social worker in the acute care setting.

Care Coordination and Transitions of Care Activities Based on The Joint Commission Standards (TJC, 2015):

1. Before admission: The hospital must identify and use available information sources about the patient’s needs and communicate with other care settings for this purpose.

2. During admission: The hospital provides services that are consistent with its mission and the population it serves. It must make arrangements with other facilities to facilitate patients’ admission or transfer as indicated by their needs and based on intensity, risk, and staffing levels. In addition, it must refer patients to clinical consultants and providers of contractual agencies as appropriate.

3. While in the hospital: Continuity of services must be maintained throughout the phases of assessment, treatment, and reassessment of patients, and the care provided must be coordinated among all providers.

4. Before discharge or transition: The patient’s post-discharge needs must be evaluated and arrangements made to meet these needs, including patient/family teaching regarding such care. The hospital must assess and reassess the patient’s needs on an ongoing basis and confirm or modify the discharge/transitional plan accordingly and keep the patient informed of the plan.

5. At time of discharge or transition: The patient must be referred to other providers or agencies to provide the needed post-discharge services. Such arrangements also must be reassessed and confirmed before discharge. The hospital is required to communicate relevant information to the agency that will assume responsibility for continuing care after the patient’s discharge.

6. Any time during care provision or transition: The hospital must inform the patient or the patient’s family about the freedom to choose any participating providers of services needed post-discharge, such as home healthcare, skilled care, and infusion therapy — and, when possible, respect the patient’s choice. If the patient belongs to the Medicare benefit program, the hospital must give the patient a list of Medicare participating home care, skilled care, or infusion therapy providers available near him or her. If the patient belongs to a commercial health insurance or managed care plan, the hospital must provide the patient with a list of the contracted providers for the commercial insurance or managed care organization.

7. Before discharge or transition: The hospital must educate the patient and the patient’s family about the discharge, transfer, or transition including the treatments, services, and follow-up care. The hospital also must complete the required paperwork to adhere to the law and accreditation standards such as notice of discharge or transition.

Patient Flow and Coordination of Care

In best practice case management models, case managers and social workers spend a great deal of their time coordinating and facilitating patient care activities and expediting the completion of diagnostic and therapeutic tests, treatments, and procedures. They also ensure that the results of the tests and procedures are available within a reasonable turnaround time. This function is important in reducing length of stay, enhancing treatment progression, and eliminating delays and variances in patient care activities and outcomes. In collaboration with members of the healthcare team, they help patients move smoothly and safely through the hospital and healthcare system.

In this role, case managers prevent any fragmentation or duplication in the provision of care. Their timely interventions when a patient’s condition changes increases the efficiency and effectiveness of care and promotes safe and quality care outcomes. When necessary, case managers and social workers ensure that authorizations for services are obtained before initiation of treatment. They also coordinate the patient’s teaching and discharge plans and ensure the completion of all discharge activities in a timely fashion to prevent unnecessary hospital stays or readmissions. This role is important in controlling the use of product and personnel resources, enhancing the safety and quality of care, and containing cost.

Case managers function as managers of healthcare services so that the patient receives exactly what he or she needs, no more and no less. They act as gatekeepers of the interdisciplinary healthcare team to ensure that all patient care activities are accomplished by each team member within the expected time frames. In addition, especially in the acute care setting, the case manager often is responsible for ensuring that appropriate members of the healthcare team participate in the daily patient care management rounds.

Interdisciplinary Care Rounds

The case management team provides an important role in identifying and correcting delays or gaps in service as they occur and works to correct and eliminate those gaps and delays in a timely manner. Interdisciplinary care rounds are an important tool that the case manager can use to ensure that he or she has the most up-to-date information on the patient’s progress toward expected outcomes and to intervene when those gaps need to be corrected. Rounds, if performed correctly, can be the most efficient and time-effective way to get information from, and give information to, the other members of the care team.

After rounds, the case manager and social worker take the time needed to address the identified delays and regroup with appropriate team members later in the day to review any progress made or barriers that were not corrected. This care coordination role is integral to length-of-stay management, cost containment, and achievement of expected outcomes of care. It is one of the most important tools we have for patient flow management.

It is important to remember that rounds are not change-of-shift reports. They should not be used for the staff nurses to exchange reports or for the physicians to exchange theirs. Interdisciplinary care rounds are designed as a separate, yet vital, mechanism for bringing the key team members together and working in a coordinated manner to ensure that patients’ care progresses and that resources are used appropriately. With this end in mind, interdisciplinary care rounds should focus on:

• The inpatient plan of care, including the plan for the day and the plan for the stay by:

-reviewing the patient’s current status;

-coordinating care among disciplines.

• The daily and overall expected outcomes of care by identifying and clarifying the patient’s goals and desired outcomes.

• Any barriers to care delivery or discharge, including:

-insurance/payment issues;

-family or patient delays;

-changes in the patient’s condition.

• Expected care transitions during the inpatient phase. Examples include:

-intensive care to step-down unit;

-observation status to inpatient admission;

-ambulatory surgery to in-patient admission.

• The current discharge plan and rationale for the plan.

Benefits of Rounds for Care Coordination

Rounds provide a mechanism for the creation of a comprehensive plan of care that involves and includes the entire care team. By bringing rounds to the bedside, the team allows the patient and family to become the center of the patient care activities. This can result in a tremendous difference from when the patient and family are not included. It allows them to understand the care progression plan, participate in the process, and ask questions about their care. By allowing these discussions with the care team, opportunities for the team to contradict each other, or be unresponsive to any concerns they may have, are reduced.

Within 1-2 minutes per patient, the team achieves the following:

• patient interaction at the bedside;

• focused, quick assessment;

• an updated plan of care that is agreed to by all team members;

• safety check;

• environmental check;

• regulatory check;

• staff education;

• patient/family education.

Within the current demands of healthcare, this culture of safety, transparency, efficiency, collaboration, and autonomy makes a big difference in the quality of care patients receive. At the foundation is care coordination — it is the key driver and a component of the expected outcomes of the process.

Rounding is so important because it allows for a real-time exchange of information as the interdisciplinary care team interacts with each other and with the patient and family. Because these interactions and conversations take place in this way, the goals and plan of care for each patient are clear to all members of the team, and any conflicts or needed changes can be made quickly and efficiently.

Team communication is critical to good care coordination. Rounds provide a formal and organized approach to patient care that ensures the patient and family receive consistent and accurate information. Rounds also enhance efficiency and safety of patient care.

Variances and Coordination of Care

Another key role of the case manager and social worker is the real-time identification and correction of any barriers or delays in care delivery or discharge. Known as variance, avoidable days, or avoidable delays, their rapid identification allows the case manager or other members of the team the opportunity to address and correct them as they happen, or as quickly thereafter as possible. They fall into one of several categories based on the root cause of the delay.

• Internal or hospital systems: Issues related to the hospital’s internal systems such as radiology, transportation, etc.

• External systems: Issues related to systems outside the hospital, such as ambulance delays, delays in bed availability, etc.

• Patient/family: Delays attributed to the patient or family, including changes in clinical condition, delays in decision-making, or financial issues.

• Provider: Includes any direct care provider on the team and includes delays in order-writing, delays in progressing care, or lack of communication.

• Payer: Includes any delays attributed to a third-party payer, such as authorization delays.

The Role of the Case Manager in Correcting Delays in Service

The case manager and social worker are responsible for correcting patient flow and care coordination barriers as they occur. They also are responsible for entering these delays into a database for aggregation and analysis. These analyses allow for the correction of service or provider delays that represent those that have a greater effect on care delivery.


Case managers and social workers, as well as case management departments in general, should be adequately designed and staffed to allow for the time-intensive nature of care coordination. This role should be considered just as important as discharge planning or utilization management if case managers and departments are to achieve and sustain better outcomes for their patients and organizations.