Q&A: Roles and functions in ambulatory care management
Q: Can you point me toward opportunities for doing case management work in ambulatory care?
A: Organizations are evaluating their system and the long-term needs of patients, and they are embracing roles to ensure that patients and families have the support that they need. Some of these positions include the following:
Ambulatory case managers: These RN positions manage high-risk and rising-risk patients in primary care sites. These positions act in a generalist role, and job duties include the following:
- Managing preventive care needs
- Flagging and intervening in at-risk patient populations
- Assessment for psychosocial distress and referrals to social work
Nurse navigators: These RN positions were developed to manage patients across the continuum of a focused event, such as orthopedic or cardiac surgery or cancer treatment. These positions often require the clinician to follow the patient across the continuum of care, from diagnosis to recovery from an acute event. These positions include the following:
- Patient educations
- Assessment for psychosocial distress and referrals to social work
- Assess, secure, and coordinate appropriate services across the patient’s acute illness
Health coaches: Those who fill these positions typically have an associate’s degree or some type of medical background. In collaboration with the work of an RN ambulatory case manager, they focus on the needs of lower-risk patients and offer the following services:
- Providing self-management
- Bridging the gap between clinician and patient
- Helping the patient navigate the healthcare system
- Offering ongoing emotional support
- Serving as a continuity figure, ensuring that the patient has the elements of what he or she needs to keep moving forward (e.g., transportation, food)
Ambulatory social workers: Those in this position work with patients who are at risk for over-utilization of medical resources and identify patients with psychosocial needs, both related to illness as well as related to the resolution of social determinants of health. Thus, the role of ambulatory social workers often includes providing the following services:
- Setting up adjustment to illness counseling
- Identifying the need for and connection to community resources
- Identifying the need for and connection to entitlements programs
- Connecting patients to support groups
- Connecting patients to mental health services
All of these roles have been developed to manage cost and utilization both for the provider and the patients, as the change is being driven by reimbursement and availability of and access to services. Case management has become a critical role for all players of the healthcare system, from the payer to the provider.
For more information, see Care Transitions in Case Management. 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.