Critical Path Network: Case Management Services Roles

The RN case manager will:

  • Review charts, looking at:
    • 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.