Resolving social work vs. case management conflict

It can be a discharge planning dilemma

By Karen Zander, RN, MS, CS, CMAC, FAAN

Principal

Center for Case Management

South Natick, MA

Social work in the acute care setting has lost its bearings, and assuming discharge planning under the case management umbrella is not the surest avenue to a strong professional identity. Hospital case management currently takes many forms. It has evolved recently to encompass functions that enable the facility to manage legal, financial, and quality risks:

denial and utilization review — matching payer with day-using criteria (may include quality assurance and coding);

utilization management — justifying appropriate utilization of resources per day based on criteria;

discharge planning — managing the stay from door to door, collaboratively determining level of care, and working with social work services to connect the patient to postacute services;

episode recovery — period from crisis to recovery or stabilization and tracking across time and venue (includes continuous quality improvement);

continuum — an infinite time frame, which includes a person’s health and lifestyle (may include chronic but stable states such as well-maintained diabetes or handicaps, includes disease management and long-term care).

Typically, the functions are limited or dispersed in a structure that does not require one person to complete all the functions. Nurses have traditionally filled all the functions while social work has led the way in community-based case management — the health and prevention sphere — for specific client populations such as healthy seniors. Pertinent to this discussion is the all-too-common practice of pigeonholing social workers into discharge planning rather than full use of the profession’s clinical expertise. (See the October issue of Hospital Case Management for its story on turf battles, p. 169.)

Discharge planning is a legally regulated function that has increased exponentially in complexity since the onset of managed care, the Balanced Budget Act, and proliferation of new levels of care and services.1 With shorter lengths of stay and more postacute options, more patients require use of continuing nursing services in some capacity. Therefore, discharge planning should be the responsibility of nurse case managers who can best determine the level of care needs that will ensure recovery, stabilization, or a comfortable death.

Accurate discharge planning cannot occur without in-depth knowledge of each family’s concerns and needs. Unfortunately, social workers, under the name of case management, have been so bogged down handling utilization review, placement calls, ambulance arrangements, finances, and a multitude of clerical activities, they have neither the time nor, in many hospitals, the staff to independently and thoroughly assess and risk-stratify every family. Instead, social workers respond after staff nurses, physicians, or case managers alert them to overt needs, subsequently spending the majority of time with the patient, the referral agencies, and the payer rather than the family.

As a result, families become isolated and feel unprepared for consequences of the physician’s and hospital’s discharge decision. Without an independent social work assessment, issues that can cause a real problem for patients often go undetected. Discharge planning continues to be a crisis, and readmission rates are at levels that should cause acute care professionals to be alarmed and ashamed.

The crisis is largely created by the custom of anticipating whether patients will have simple or complex postacute needs, with "simple" situations referred to nurses and "complex" situations referred to social workers. Rather, social workers who are clinically oriented should be instrumental in helping the team determine if cases are simple or complex based on a family assessment. They also should be involved with any family or patient needing psychosocial support for reactions to hospitalization, the meaning of the illness, the implications of the diagnosis, and the proposed treatment plan including guardianship, regardless of discharge planning needs.

Health care desperately needs clinical social work to offer compassion, problem-solving, and initial healing through individual, family, and group interventions. Common ground between nurse case managers and social workers is the story of the patient-family: who they are and what they need as a result of this hospitalization. The case manager’s focus is the patient, payer, and physician. The social worker’s focus is the family and the services in the community.

The result is that each patient and family is assessed in person — not second-hand via charts — and collaboratively risk-stratified for problems with meeting self-care outcomes at the conclusion of acute care. The case manager negotiates level of care (activities of daily living) with the payer, while the social worker determines services (instrumental activities of daily living) for those patients and families not moving to continuing nursing care. Both must be assisted by high-level clerical staff who research and book placements, compile patient and community information, and schedule appointments.

In summary, here are six ways to resolve the conflict over discharge planning:

1. Establish the social worker as ambassador of the hospital to the families of your community. In many instances, the social worker is the only consistent contact for families.

2. Pair social workers with case managers, but hold the nurse case manager accountable for the accurate discharge plan, specifically determining the level of care.

3. Refocus social workers on assessing the need for postacute services based on the family/significant others’ information in collaboration with the physician, case manager, and direct care staff within 24 hours of admission.

4. Set productivity standards for social workers’ overall caseloads, volume per day, and groups per week.

5. Provide upgraded, intensified clerical support to the case management and social work departments.

6. Improve the use of discharge planning rounds, requiring that social work have all family information by the first rounds following admission to enable the team to conduct a precise stratification of risk.

Karen Zander is principal and co-owner of The Center for Case Management in South Natick, MA, an international consulting firm dedicated to tools, roles, and systems that produce outcome-driven patient care. In addition, Zander maintains a private practice in psychotherapy. Contact: (508) 651-2600.

Reference

1. Birmingham J. Discharge Planning: The Rules and Reality. South Natick: Center for Case Management; 1999.

[Editor’s note: How do you feel about the points the author of this article made? Are they valid? How do they pertain to your particular situation? We’d like to hear your reaction. Contact editor Dorothy Pennachio at (201) 760-8700; fax: (201) 760-8709; or e-mail: dorothy.pennachio@medec.com.]