As you develop a case management program, recognize the importance of clarifying case management and coordination to the provider, payer, and consumer. It is also important to understand the basic and standardized roles of the RN case manager and clinical social worker.
Death and dying processes require sensitive discussion between patients, next-of-kin, and inpatient providers (i.e., attending/hospitalist physician) to facilitate decision-making and coordination of care. Social workers can facilitate such communication and may coordinate meetings between relevant persons.
Trauma-informed care is an approach to providing care that recognizes and understands how past trauma—such as child abuse, domestic violence, or events like natural disasters, car accidents, or crime—may affect a person so the provider can respond in a way that promotes safety and avoids re-traumatizing that person.
Time management in case management services across the continuum comprises three concepts: Cognitive work rather than multitasking, funneling the caseload to a workload, and fluid reprioritization of 8–15 “juicy jobs.”
Some patients seem resistant to interventions aimed at helping them avoid preventable hospital visits. These so-called high utilizers typically have multiple chronic conditions, along with social or psychological conditions and/or substance use issues that can interfere with effective care. AbsoluteCARE, an ambulatory ICU, was created for these patients.