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The line in the sand: Social workers, case managers
What matters in the end?
The blurring of lines between the role of social worker and nurse case manager in discharge planning has been the source of tension between the two specialties for more than two decades. But one expert says some organizations spend perhaps a little too much time defining roles and too little time figuring out ways to share responsibility.
“There’s a lot of tension in some organizations because the role of the social worker has been poorly defined,” suggests Steve Blau, MBA, MSW, director of case management at Good Samaritan Hospital in Baltimore. “Ten to 15 years ago, social worker leadership [in discharge planning] changed over to nurse case manager leadership. The social worker position remained, but many of the duties were shifted to case managers.”
In many hospitals, social workers can recall when they led discharge planning, and can’t shake the feeling that they can perform the same role as a case manager; hand in hand with this, Blau says, is the issue of compensation.
“I don’t think social workers or case managers understand compensation,” Blau says. “A social worker might think, ‘I should get the same pay for the same work,’ but that’s not how compensation is done, and if [case managers and social workers] are truly doing the same work, then there’s a problem with the leadership and structure in the organization.
“If you blur the lines without leadership, that blurring can become hostile,” he adds.
But while some organizations might have blended the roles of social worker and nurse case manager so thoroughly that there is little discernable difference in what they do, others spend too much time, Blau says, defining roles and delineating responsibility.
“Salary isn’t what brings people to work. They need to see where they fit in, how they contribute, and that their contributions are recognized,” he adds.
Different approaches, none right or wrong
Social workers and nurse case managers each contribute to case management and discharge planning, and the most productive approach is one that recognizes the unique contributions of each while fostering an atmosphere of “we’re all in this together,” says Blau.
“Every hospital has a different spin on how they handle case management functions,” he points out. “I have seen hospitals carve it up in many ways — three people doing three different jobs [utilization management, care coordination, and discharge planning], in a triad or collaborative model. Other hospitals use an integrated model with one person doing all three, or one person doing one thing, while another person does a combination of the other aspects.”
A contributor to differences in the use of nurse discharge planners and social work discharge planners is the kind of institution they’re in, and where they are located, according to Diane Holliman, PhD, MPH, MSW, associate professor in the social work division at Valdosta State University in Georgia. In 2003, Holliman and her colleagues reported that social workers are more likely to work in federal and state hospitals and larger hospitals with more than 250 beds, while private hospitals and hospitals with 250 or fewer beds are more likely to employ nurse discharge planners.1 That scenario hasn’t changed much since the study was completed, she tells Discharge Planning Advisor.
“From what I have seen in recent years from my students and their practice, larger hospitals such as VA hospitals, university hospitals, and state psychiatric facilities seem to have larger teams with more professional diversity — social work, nursing, physical therapy, occupational therapy, and so forth,” says Holliman. “More services for patients, more resources — but also more turf battles.”
Because there is not a great deal of consistency across the U.S. health care spectrum in how social workers and nurse case managers are deployed, Blau suggests there is no right or wrong model.
“You need to look at the standard of care, and you’d be hard-pressed to find which way is best,” he explains. “We haven’t defined it richly enough to say one way is best, and because it’s vague and open to discretion, we suffer a little as an industry.”
It’s a two-edged sword, Blau adds. “We can’t talk enough about the differences between case managers and social workers, but we can also talk about it to the extent that it’s a distraction. Sometimes, we’re so stuck on the role of the social worker that the world is moving forward and we’re missing opportunities to ingratiate ourselves into the organization.”
Holliman wrote in her 2003 report: “The primary debate on discharge planning focuses on who should be doing it and what should be done... Despite the continuous debates about who should perform discharge planning, there is no empirical evidence that one group is more qualified than the other.”
1. Holliman D, Dziegielewski SF, Teare R. Differences and similarities between social work and nurse discharge planners. Health Soc Work 2003;28:224-231.
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