Critical Path Network: Case Management Services Roles
The RN case manager will:
- Review charts, looking
- clinical, social, and financial information;
- progression of care;
- timeliness of procedures.
- Conduct insurance reviews:
- Identify potential quality issues.
- Enter Medicare patients in InterQual database (utilization review).
- Coordinate and monitor insurance benefits through clinical reviews.
- Communicate and collaborate with physicians to move patients along the continuum of care.
- Conduct daily care conferences to assess correct level of care and discharge plans.
The social worker will:
- Assess and evaluate patient’s psychosocial, emotional, financial, and cultural needs.
- Identify barriers to discharge.
- Assist in identifying and making referrals to community resources.
- Conduct patient/family interviews as needed.
- Provide counseling as needed.
- Facilitate patients/families in their adjustment/transition to changes related to illness.
- Assist in complex discharge planning.
As a team, the case manager and social worker will:
- Facilitate discharge plan.
- Conduct formal and informal multidisciplinary meetings regarding appropriateness of discharge plan.
- Report to the Utilization Management Committee under the direction of Medical Director, Dr. William F. Barnes.
Goals of the team are to:
- Decrease length of stay related to delays in care.
- Promote efficient use of patient and hospital resources.
- Identify variances per admission, continued stay, and discharge criteria using InterQual.
- Provide patterns in trend analysis to evaluate clinical outcomes.
- Improve financial and clinical processes.
Source: Kim M. Pointer, INTEGRIS Health, Oklahoma City.