Team-based care in longitudinal case management
Case managers must be positioned (through the organizational structure) and must position themselves (through skills and knowledge) to be an instrumental and influential member of the team to support and monitor the development of a comprehensive and sustainable plan for the patient.
Focus first on the partnership between the case manager and the social worker, where the two intersect, and their knowledge of all aspects of the patient’s situation (clinical, psychosocial, and financial). Moving beyond that to the hospital and clinic RNs, providers, payers, therapists, and pharmacists, these roles are all, in some way, dependent on the information and power that the case managers hold.
For example, is that high-cost medication realistic for the patient? Do the physicians understand the social deterrents that could interfere with recovery? Does the therapist understand how much therapy is covered for the patient? And does the patient and/or caregiver truly understand how to be successful? The case manager and social worker can hold the key to pulling a successful care plan together and ensuring that the plan is workable and sustainable.
Elements of team-based care in a longitudinal model include the following:
- Alignment: Ensuring that all members of the team understand and agree upon the same patient goals (including the patient and family as members of the team)
- Lateral leadership: Helping to influence outcomes through effective communications within a patient-centered approach
- Team-based decision-making: Providing knowledge of the patient from a longitudinal perspective as a contribution to the team’s development of a care plan
For more information, see Longitudinal Case Management: Designs Across the Continuum of Care.