SWs, CMs collaborate for better patient care

No one says, That’s not my job’

A few years ago, the master’s prepared social workers (MSWs) and RN case managers at Hoag Memorial Hospital Presbyterian in Orange County, CA, were having the usual disagreements over who should do what for which patient and who was carrying the heavier load.

Now, after instituting a collaborative practice model, the two disciplines work together as a team, sharing the caseload on the unit to meet the patients’ identified needs. The two disciplines have cross-trained each other on job functions that do not require the specialty of the discipline so that social workers can call the insurance company to get benefit information and the case managers help families find community services they need when it’s necessary. The areas that are the specialty of the respective disciplines are utilization management for the RNs and psychiatric issues for the MSWs.

Along with the increase in productivity has come an increase in morale and professional satisfaction, says Theresa Thomsen, LCSW, manager of the social work department at the 409-bed hospital.

"We now have a more diversified, more valuable team. When there’s a sick person in the family, there are a lot of psychosocial issues that have to be handled along with the other care coordination. It all works together," says Paula Griego, RN, BSN, manager of the case management department.

When the two departments began working to develop their collaborative practice model, the hospital had four social workers and eight RN case managers whose main jobs were utilization review and discharge planning. The RN case managers were assigned by unit and called in the social workers when they were needed for psychosocial issues. "With that model comes a lot of disagreements about who does what. The RN case managers felt they had a heavy load to carry, and the social workers often felt their accountability was being questioned," Thomsen says. Among the goals of the model are to build strong communication between the disciplines and to get rid of the slogan, "That’s not my job."

The changes in the social work and case management departments occurred when Hoag Memorial was going through the process of rebuilding employee morale. During the hospitalwide initiative, each department created "Just Do It" groups, which met regularly to set goals for working together, to identify barriers to reaching the goals, and to come up with ways to overcome them.

"The hospital administration wanted to get rid of the critical, blaming nature the hospital had been functioning in and build a customer service model for the internal and external staff, everyone from the patient to the doctor to the ancillary staff," says Thomsen.

The fact that the hospital’s initiatives were being reinforced within and outside of the departments lent itself very well to the changes the managers wanted to make in the social work and case management departments, Griego adds.

The case management and social work departments began by calling in consultants to introduce them to different models for assigning the work. Now the hospital has an equal number of social workers and RN case managers on the staff during the day. They are assigned by unit and work as a team. The case managers and social workers on each unit have created a partnership and work closely together when patients have complex social and clinical issues that need to be co-managed.

"A collaborative relationship is more effective in accomplishing more favorable outcomes for the patient, "Griego says.

With a more balanced workload, the nurse case manager can take time to build rapport with the patient and provide support, she adds. "We do a lot of cross-training, but if one person starts with the case and needs to call in the other discipline, they do so. Each discipline calls on its partner and counterpart to help with complex cases."

The social workers and case managers go on rounds together on a daily basis.

If a case manager or social worker consistently has to work late, the other team member will work with him or her to alleviate the problem. "That builds confidence with each other. They know they’re not going to be left alone," Thomsen adds.

Often, there are a few cases that need a lot of service. That’s when the teams work together to share the load, Griego explains.

The department managers follow the model as well, going on the floor and taking care of whatever needs to be done as an example to their staffs. "The most positive way to get individuals to work together is to be a role model. You have to be willing as a manager to show the other social workers that you’re willing to get in there and pick up cases or call insurance companies, even though historically, it’s not a social worker’s job. You’ve got to show the staff that it’s OK to do it and that this is the service level you expect," Thomsen says.

She was eager to improve the collaboration between case management and social work because she had witnessed other social work departments getting smaller and smaller because of a budget crunch. "When money is tight, it’s easy to justify cutting down on social work in a medical facility. We have to build our capabilities within our organizations and do things like discharge planning and following patients through the process in order to survive in a medical setting."

Social workers didn’t receive the same kind of regard as case managers before the initiative began, Thomsen says. "It has been my experience that the profession of social work is not understood by everyone from hospital administrators to nurses to physicians." The social work department spends a lot of time educating hospital personnel on the educational level of social workers and the broad range of abilities they can handle in the medical setting, she adds.

"They weren’t viewed as someone who could carry the ball. They came in and did what they could and left the nurse case manager feeling responsible for the case," Thomsen states. As the hospital restructured the working relationship between the RN case managers and the MSWs, they emphasize the importance of equal accountability to their assigned unit, she says.

Social workers were encouraged to take full responsibility for the patients assigned to them, and RN case managers were encouraged to move from a direct management role to a support role with certain patients, she adds. "Now the social workers know that they can handle whatever comes their way. They have a Don’t worry; I’ll take care of it’ type of attitude, and it builds their value." Recently, other parts of the hospital have begun requesting social workers on their team.

"The emergency room wanted a social worker. Then they asked for one in the ICU. The administration came to me and said they wanted to add more positions in my department," Thomsen adds. The fact that the initiative has resulted in new staff positions has helped smooth the process. "It did make a difference that the newer people coming in didn’t have the preconceived mentality of being comfortable with the way things were and not wanting to change. The newer people coming into the organization have looked beyond the age space. They have lunch together and do things together after work," Thomsen says. As she’s hired new staff, she has looked for people who want to be a team player and who are eager to learn.

When she interviews candidates for case management positions, Griego often encounters surprise at the model because it’s so different from what’s in place in most hospitals. "A collaborative model promotes open accountability between the disciplines and is much more effective than traditional models. Now the staff members say it is such a pleasure to work here because we are more effective working as a team," she adds.