Q&A: Role clarification in effective case management models

Q: Do you have any tips for developing a hospital case management model that we can use to evaluate effectiveness across all levels of care?

A: Any effective case management model that creates positive results requires role clarification. Of course, anyone at the bedside knows that not everything about roles can be prescribed. There will always be some overlap between case managers and social work, between social work and physicians, between nurses and physical therapy, etc.

Each role is really a negotiation between other people, including the patient and family. The role is based on the official job description, but not exactly as written in every situation. And the job description is based on the model but cannot define every activity. Both the function of care coordination within the case manager role and the role of the clinical social worker require the most creativity.

It is helpful at the onset of any new model to map out a set of documents that describes how things will look (the vision), algorithms for process steps that require decision points, and side-by-side tables to show how major responsibilities dovetail. This also helps with the identification of any gaps. Defined core functions may include: access, UR/UM/CDI, care coordination, discharge planning, recovery, continuum, and contracting.  

For more information, see Case Management Models: Best Practices for Health Systems and ACOs, Second Edition. Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.