Nursing Mngt

Professional Case Management Vol. 18 , No. 5 , 246 -254 Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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CE

There have been numerous studies attempting to defi ne case management roles, responsibilities, and essential functions (Tahan & Campagna, 2010). Given the diversity of settings, case manage-ment models, and organizational idiosyncrasies, most studies tend to produce vague, overgeneralized fi nd-ings and one-size-fi ts-all assertions. Responses to survey questions often refl ect research bias, given the tendency to provide socially desirable responses. The American Nurses Credentialing Center (ANCC) conducted an extensive Nursing Case Management Role Delineation Study, identifying 66 work activities ranked hierarchically by overall criticality (ANCC, 2011, p. 6). The ANCC (2011) states, Role delin-eation or job analysis studies are typically carried out at the national level with the goal of describing current practice expectations, performance require-ments, and environments. ANCC has a current goal of conducting a study of each specialty approxi-mately every three years in order to capture changes in work activities and the knowledge and skill areas required to perform those activities. The fi ndings are used to update the content of its respective certifi ca-tion examination (p. 5). But do role and function studies actually capture the day-to-day involvement, interests, and struggles of hospital case managers?

Hospital case managers have been described as professionals in the hospital setting who ensure that

patients are admitted and transitioned to the appropri-ate level of care, have an effective plan of care and are receiving prescribed treatment, and have an advocate for services and plans needed during and after their stay (Wikipedia, n.d., para. 3). Key roles associated with hospital case management include variance analy-sis, care coordination, optimal patient and hospital out-comes, quality of care, effi cient resource utilization, and reimbursement for services (Wikipedia, n.d., para. 3). Phaneuf (2008) provides an extensive overview of the nursing case management role. However, the overview fails to capture the present inordinate emphasis on Cen-ters for Medicare and Medicaid Services (CMS) compli-ance and utilization review. One study reports, Almost two thirds of case managers say that patient satisfaction is the number one factor they consider when evaluat-ing a case managers performance (Health Law and Regulation, 2010, para. 3). Others stress, Case manag-ers freed from the need to perform routine chart reviews can work with physicians to manage progression of

Address correspondence to John J. Reynolds, BA, LCSW, Care Management & Patient Access, Saint Vincents Medical Center, 47 Long Lots Rd., Westport, CT 06880 ( [email protected] )

The author reports no confl icts of interest.

A B S T R A C T

Purpose of the Study: The purpose of this study was to identify the roles, functions, and types of activities that hospital case managers engage in on a day-to-day basis and that leverage the most amounts of time. Previous studies superimpose a priori categories on research tools. Practice Setting: Hospital case management. Methodology and Sample: This study analyzes 4,064 spontaneous, unstructured list serve postings from the American Case Management Association Learning Link list serve from August 15, 2011, to August 18, 2012. The study group was a cross section of 415 case management professionals. Implications for Practice: The data suggest that hospital case managers time is inordinately leveraged by issues related to observation status/leveling of patients and the Centers for Medicare and Medicaid Services compliance. The data also suggest that hospital case management has taken a conceptual trajectory that has deviated signifi cantly from what was initially conceived (quality, advocacy, and care coordination) and what is publicly purported. Case management education and practical orientation will need to be commensurate with this emerging emphasis. Case management leadership will need to be adept at mitigating the stresses of role confusion, role confl ict, and role ambiguity.

Key words: compliance , functions , role confl ict , roles

Another Look at Roles and Functions Has Hospital Case Management Lost Its Way?

John J. Reynolds , BA, LCSW

DOI: 10.1097/NCM.0b013e31829c8aa8

NCM200342.indd 246NCM200342.indd 246 7/30/13 7:24 PM7/30/13 7:24 PM

Vol. 18/No. 5 Professional Case Management 247

Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

managers are immersed in, the author conducted a content analysis of 4,064 list serve postings on the American Case Management Association (ACMA) Learning Link, from August 18, 2011, to August 18, 2012. ACMAs Learning Link is described as a vast electronic network that connects members through an e-mail list serve. Members ask questions and share their experiences, tools, resources, successes, and per-spectives. When you have a question or challenge, over 2,500 case management professionals are only an e-mail away. Learning Link is provided as a Mem-ber benefi t of the American Case Management Asso-ciation (ACMA website, n.d.; Learning Link: Whos in Your Network? para. 2 and 3). Also, it should be noted, ACMA accepts no responsibility for the opin-ions and information posted on this site by others. ACMA disclaims all warranties with regard to infor-mation posted on this site, whether posted by ACMA or any third party (ACMA website, n.d., Learning Link Disclaimer & Legal Rules, para. 1).

Postings were placed by 415 hospital case man-agers and physicians. Postings were categorized by subject heading and assessment of content for salient themes. Subject categories are not mutually exclusive, because postings might cross-reference other catego-ries. As with all studies, data interpretation rests on certain assumptions. These data assume that the case managers postings on the ACMA Learning Link are a representative sample of hospital case management professionals and medical consultants. Therefore, the fi ndings are subject to multiple interpretations. Figures 1 to 3 are accompanied by a glossary that operationally defi nes the fi gure categories.

FINDINGS

The data illustrate that the issues related to the CMS compliance, 719 posts (18%), and specifi cally observa-tion status and the accurate leveling of patients, and 935 posts (23%), have emerged as an intractable lever-age of time for hospital case managers ( Figure 1 ). It is surprising that observation status was identifi ed as a problem area in 1994, with the Health Care Financing Administration publishing rules for appropriate utili-zation of observation status in 1996, followed by the inclusion of observation status in the Offi ce of Inspector General Work Plan in 1998 (HCPro Inc, 2008). Utiliza-tion review committees have been authorized to change patients status from inpatient to outpatient since 2004 (Center for Medicare Advocacy, n.d.). Nonetheless, despite more than 18 years of grappling with the issue, hospital case managers seem shackled to observation status and the appropriate leveling of patients.

Discharge planning/care transitions ranks a dis-tant third with 579 posts (14%), and best practice/quality only (6%), metrics/outcomes 77 posts (2%).

care from hospital to community (Daniels & Frater, 2011, para. 3). In The Gestalt of Case Management, Powell (2012) notes the following job titles encompass-ing case management: care coordinator; case manager; care manager; clinical resource coordinator; guided care nurse; health coach; medical home care coordina-tor; patient navigator; patient motivator; resource coor-dinator; resource manager; transition coach; utilization manager; and discharge planner.

The Case Management Society of America (2010) promulgates the following standard for case manage-ment: Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individuals and familys comprehensive health needs through communication and available resources to promote quality cost effective outcomes (p. 8).

The Case Management Society of America 2010 standards (p. 7) assert that their standards refl ect many changes in the industry, which resonate with current practice today. Some of these changes include the following:

Minimizing fraxgmentation in the health care system

Incorporating adherence guidelines and other standardized practice tools

Using evidence-based guidelines in practice Expanding the interdisciplinary team in planning

care for individuals Navigating transitions of care Improving patient safety

The underlying premise of case management is based in the fact that, when an individual reaches the optimum level of wellness and functional capability, everyone benefi ts: the individuals being served, their support systems, the health care delivery systems, and the various reimbursement sources. Case management serves as a means for achieving client wellness and autonomy through advocacy, communication, education, identifi cation of service resources, and service facilitation. Case management services are best offered in a climate that allows direct communication between the case manager, the client, and appropriate service personnel, in order to optimize the outcome for all concerned. (Case Management Society of America, 2010, p. 9)

Although laudatory, do these high-level rhetori-cal statements of standards resonate with actual hos-pital case management activity?

METHODOLOGY

In an attempt to cast light on the actual day-to-day roles, tasks, functions, and issues that hospital case


Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.248 Professional Case Management Vol. 18/No. 5

Utilization review has a primary goal that is adminis-trative in nature, that is, to place patients in the proper status and fulfi ll our obligation to provide assistance as to the optimal utilization of resources and patient care. It is stated at the outset that these issues are marked by potential confl ict between patient care and plac-ing barriers to that care (p. 263). Daniels and Reece (2007) state, Because their work was heavily centered on utilization review tasks, nurses became the chart police and the instruments for growing chart review activities, such as core measure abstracting, medi-cal documentation review, concurrent coding assign-ments, safety indicators, and numerous other perfor-mance improvement projects. The idea of resource appropriateness, advocacy, and navigation through the episode of care, cost reductions, and improved qual-ity vanished, except for an obligatory mention in the job description (para. 3). The 4,064 ACMA Learn-ing Link postings call into question the initial vision of case management. With the big picture perspec-tive, the hospital case manager harnesses the collective wisdom of the clinical team to assess, plan, and con-tinuously evaluate the patients post-acute experience (Phoenix Medical Management, n.d., para. 6).

Figure 2 integrates the combined impact of CMS com-pliance issues and distinct compliance and revenue integrity issues related to observation status account-ing for 1,654 (41%) of all postings. If we were to consider the revenue implications of compliance and observation and combine those categories with Bill-ing, Utilization Review Criteria, Physician Advisor, and Denials, Figure 3 illustrates a combined impact of 2,348 (58%). This is signifi cant, because case manag-ers often fi nd that organizational business imperatives often confl ict with other facets of their professional identity, such as patient advocate. Of note is that Team Building received less than 1% of the overall postings. This may suggest that Team Building has been satisfactorily addressed by organizations or that other activities preclude team building activities.

DISCUSSION

The frequency distribution among categories suggests that hospital case management is strategically posi-tioned to impact revenue and manage risk. However, has it done so at the opportunity cost of commitment to quality and patient advocacy? Cohen (2012) notes,

FIGURE 1 Hospital case management role and function as refl ected by American Case Management Association Learning Link posts from August 15, 2011, to August 18, 2012 (n = 4,064). ADM = admission; DCP = discharge planning; DOC = documentation; ED = emergency department; JD = job description; OBS = observation; OP = outpatient.

935

719579

259 236 202 179 163 156 122 116 106 77 76 74 30 190

100200300400500600700800900

1000

OBS/A

DM ST

ATUS

COMP

LI

DCP/T

RANS

BEST

PRAC

STFF

NG

CRITE

RIA

DENIA

LS

BILLN

G

SOFT

WARE JD ED

READ

M

OUTC

OMES

PHYA

DV DOC OP

TEAM

Post

s

b

a

MISC0%

TEAM0%

OP1%

DOC2%

PHYSADV2%

METRICS2%READM

3% ED3%JD3%

SOFTWARE4%

BILLNG4%

DENIALS4%

CRITERIA5%STFFNG

6% BESTPRAC6%

DCP/TRANS14%

COMPLI18%

OBS/ADM STATUS23%

OBS/ADM STATUSCOMPLIDCP/TRANSBESTPRACSTFFNGCRITERIADENIALSBILLNGSOFTWAREJDEDREADMMETRICSPHYSADVDOCOPTEAMMISC




FIGURE 2 American Case Management Association Learning Link posts. DCP = discharge planning; ED = emergency department; OP, outpatient.

FIGURE 3 American Case Management Association Learning Link posts by major category and percent.

1654

831 694492 358

16190

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10001200140016001800

COMP

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S

DENI

ALS

BEST

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AM MISC

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TEAM0.5%STFFNG

9%

BESTPRACT12%

DENIALS17%

CARE TRANS20%

COMPLIANCE41%

COMPLIANCECARE TRANSDENIALSBESTPRACTSTFFNGTEAMMISC

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250 Professional Case Management Vol. 18/No. 5


no admitting privileges, write transitional orders that are confused with admission orders. The confl uence of these forces creates massive amounts of re-work that case managers are held accountable to unravel at the back end. Compliance offi cers, Departments of Revenue Integrity, too often take a step back, defer-ring to case managers who then assume responsibil-ity and liability for any missteps in what is the conver-gence of several volatile issues, leaving hospital case managers as the repositories for risk assumption.

A review of legal and regulatory issues seems to focus exclusively on Protected Health Informa-tion ( Muller, 2012 , 2013). This is consistent with the 2010 ANCC Role Delineation Study Overview sur-vey fi ndings, which ranked, maintains clients con-fi dentiality as the number one work area relative to overall criticality for hospital case managers (ANCC, 2011, p. D2). However, the slippery slope of case managements entry into billing compliance, admis-sion status determination, revenue integrity, and interpretation of CMSese as it explains, or tries to, CMS regulatory stipulations for billing and take backs have received little attention as a professional practice issue. In fact, the ANCC survey question, Reviews level of care based on utilization review cri-teria, did not rank in the surveys top-20 work items relative to overall criticality (ANCC, 2011, pp. 12).

There has been a consistent failure to capture this shift as a professional practice issue and to offer guid-ance as how to navigate the changing landscape. Per-haps the 2011 American Case Management Associa-tion National Hospital Survey (pp. 3233; this survey is available to ACMA members only) is instructive, while noting a statistically signifi cant increase in the number of case management departments reporting to operations and other departments, whereas the number of departments reporting to nursing/patient care services is almost equal to the number reporting to fi nance. This fi nding is again refl ected in the 2013 ACMA National Hospital Case Manage-ment Survey (p. 23). Role confusion, role ambiguity, role confl ict, and role tension have emerged as central themes in defi ning case management integrity as a practice specialty. There is evidence to suggest that, in varying degrees, these practice strains have not only job satisfaction and job effectiveness implications but mental health ramifi cations relative to burnout

Does the dominance of CMS compliance, patient assignment, and/ or leveling signify a risk that would fragment the unifi ed skill set of case management into individual elements creating the biggest threats to case management to building recognition of, and consistency in, the professional practice of case man-agement? ( Powell, 2012 , p. 228). I believe that the implications of the issue are exquisitely expressed in Smiths (2011) treatment of role ambiguity, role con-fusion, and role confl ict in hospital case managers.

Although less overt than in the past and ample rhetoric to the contrary, many health care organizations continue to harbor a culture of blame. Because hospi-tal operating margins continue to shrink, determining patient status and the concomitant compliance and operational implications have engendered increasing amounts of audit anxiety and undermine team cohe-sion. I have seen the abdication of other disciplines rel-ative to Observation and patient leveling create a void that case managers have been compelled to fi ll. From the framework of thermodynamic theory, entropy is a measure of a systems energy that is unavailable for work or of the degree of a systems disorder or trend toward disorder (Entropy, n.d.). I would argue that the inordinate reliance on Case Management Assignment Protocols and other fi rst-level review screening meth-odologies signify hospital case managers confronting a state of organizational and physician entropy. Because there is not a suffi cient energy contribution by other sources, hospital case managers compensate for a mul-titude of organizational systemic defi cits on the road to professional burnout.

In my own experience, with rare exception, the physician community has taken the stance that the leveling of patients is an administrative, nonclinical issue. Medical coders who have their own creden-tialing and practice guidelines consistently ask case managers how they should code on the basis of what the physician has (or has not) documented. Organi-zational goal misalignment manifests as Emergency Departments move patients out at a rate of accel-eration that precludes hospitalists accurately leveling a patient at the point of entry. Emergency department registration processes frequently do not cohere to clin-ical/regulatory requirements by using the colloquial of Admit and Observation and create a web of confusion. Emergency department physicians, with

In an effort to justify and prove our organizational worth, perhaps case management leaders inadvertently contribute to the myriad confl uence of varied roles and

expectations that are assumed and consequently required of staff. Or, maybe as helping professionals, we are all too willing to have our capacity to care exploited as

we compensate for organizational and leadership voids.




containment and fi nancial issues; some perceived this expectation as confl icting with their role as patient advocate and created tension as well as decreased job satisfaction and self-confi dence. Also was noted the participants perception of not being aware of the aspects of the case management role and of not being prepared for the role and not aware of the aspects of case management that would be problematic (Smith, 2011, p. 184). Gray, White, and Brooks-Buck (2013) astutely note, it is clear that role confl ict and role ambiguity are important intervening variables that mediate the effects of various organizational practices on individual and organizational outcomes (p. 69). The authors also found that many responses indicate that there is role confusion and confl ict and ambigu-ity related to the areas of time, resources, capabilities, and the multiplicity of roles and responsibilities. Nurse case managers are held to different sets of stan-dards that could be at odds with each other (p. 72).

It is true that case managers are a unique segment of the healthcare workforce, therefore, their unique role needs to be clearly articulated if the specialty is to gain industry-wide recognition and standardiza-tion (Gray et al., 2013, p. 72). However, there is a good reason to believe that case management has become the Swiss Army Knife of health care, engaged in quality, utilization management, denial man-agement, family intervention, discharge planning, compliance, etc. (see Figure 4 ). Although a seeming organizational convenience, the Swiss Army Knife

as hospital case managers endeavor to reconcile the many roles and expectations in a manner that is pro-fessionally acceptable.

In an effort to justify and prove our organiza-tional worth, perhaps case management leaders inadvertently contribute to the myriad confl uence of varied roles and expectations that are assumed and consequently required of staff. Or, maybe as helping professionals, we are all too willing to have our capac-ity to care exploited as we compensate for organiza-tional and leadership voids. Smith (2011) has written insightfully about role ambiguity and role confu-sion for nurses transitioning from bedside to nursing case management. Specifi cally, within the business culture and fi nancial objectives theme, participants revealed feelings of confl ict and being at odds with the employer regarding the expected focus on cost

FIGURE 4 Hospital case management and role confusion case management as the Swiss Army Knife of health care. HIM =health information management; RAC = recovery audit contractors.

John J. Reynolds

Utilization management

Quality improvement Risk

management

Discharge planning

Outcomes monitoring

Tracking variances

Regulatory compliance

Pt./Family advocacy

Teamleader

Observation/inpatient only

Billing

HIM consultant

RAC take backs

Care progression

Core measures

The frequency distribution among categories suggests that hospital case

management is strategically positioned to impact revenue and manage

risk. However, has it done so at the opportunity cost of commitment to

quality and patient advocacy?




and update where needed. Revise departmental orientation as indicated.

Use relevant articles and case vignettes at staff meetings to support staff and foster the coordi-nation and integration of specialties.

Utilize guest speakers who are subject-matter experts to support training and departmental curriculum development.

Develop presentations for professional work-shops and conferences that address the changing landscape and related skill sets while focusing on maintaining a commitment to core values.

The multitude of titles, functions, and activities that hospital case managers fi nd themselves engaged in is testament to case managements organizational value. It is no wonder that hospital case managers report role strain, role ambiguity, role confl ict, and feelings of burnout. Nonetheless, hospital case man-agement cannot be allowed to become a victim of its own aspirations and its own success.

Operational Defi nitions

Best practice/quality: Standards of care for spe-cifi c disease states, professional articles, certifi ca-tion, The Joint Commission compliance.

Billing: Non-RAC, billing-related issues. Compliance: CMS-related guidance and regula-

tory adherence. Observation: Admission status orders, RAC, pre-

payment reviews, utilization management plans. Care Transition: Diffi cult discharges, discharge

assistance programs, discharge resources, trans-fer centers; readmissions; emergency department; outpatient.

Denials: Non-CMS utilization review activity, denial management, criteria

Documentation: Issues related to clinical docu-mentation improvement and other charting issues.

Emergency department: Issues related to emer-gency department functioning, including staffi ng, coverage, job descriptions.

Outcomes: Issues related to benchmarking, tar-gets, acuity systems.

Job descriptions (nonemergency department): Issues related to various job descriptions, including case management, utilization review, transfer center.

Outpatient: Issues related to outpatient proce-dures, billing, and outpatient staff roles.

Physician advisor/physician roles: Issues related to physician advisor, attending physician, medical director roles.

Readmissions: Issues related to readmission pre-vention, tracking.

as an All in One solution is not a sustainable tool ( Fry, 2007 ; Reynolds, 2004). It is meant as a stop-gap measure, not as a long-term solution because each application is a substitute for a full size, enduring, more effi cacious specialty instrument.

Many organizations fail to recognize that hos-pital case managers provide direct care to patients. Although not necessarily at the bedside, they are direct care workers. The integration of case and manager as a job title creates a distortion of what case managers do. First, case manager implies an inordinate and misleading amount of control in the face of a multiplicity of organizational and external forces. Second, manager implies a nondirect care function with inherent hierarchical authority. I have been astounded at the amount of committee time direct care/case management staff spend in meetings, thus vitiating their direct patient service activities and creating time constraints relative to their numerous other activities.

What Can Be Done?

Case management practice education and departmen-tal leadership will need to address the actual day-to-day operational and clinical emphasis on CMS com-pliance and the interface of professional practice and organizational business imperatives and the impact on the integrity of hospital case manages role bound-aries, role confl ict, and role ambiguities.

Case management is what I call a lynchpin practice specialty with numerous spokes emanat-ing out to other departments. Heeding Powells cau-tion that case management functions need not become independent titles, I do believe that there does need to be some acknowledgment of both the specialty skill and its link to the core case management role. A com-promise nomenclature might be as follows:

Case management utilization specialist. Case management compliance/recovery audit con-

tractors specialist. Case management quality specialist. Case management discharge planning/care transi-

tion specialist. If job descriptions cannot be specialized, stipu-

late to new recruits what percentage of time is expected in each function/activity.

Create clear reporting relationships with other departments.

Orientation : Guarantee that each function receives the requisite amount and type of training/preceptorship to engender confi dence and com-petence.

Use staff meetings to explore whether current job descriptions refl ect current departmental practice




case management/utilization review software, electronic medical records, meaningful use, etc.

Compliance: CMS-related guidance and regula-tory adherence.

Observation: Admission status orders, RAC, pre-payment reviews, utilization management plans.

Discharge planning/care transitions: Diffi cult dis-charges, discharge assistance programs, discharge resources, transfer centers.

Denials: Non-CMS utilization review activity, denial management, criteria.

Physician advisor/physician roles: Issues related to physician advisor, attending physician, medi-cal director roles.

Documentation: Issues related to clinical doc-umentation improvement and other charting issues; Billing : Non-RAC, billing-related issues.

Emergency department: Issues related to emer-gency department functioning, including staffi ng, coverage, job descriptions.

Outpatient : Issues related to outpatient proce-dures, billing, and outpatient staff roles.


Staffi ng: Issues related to roles/responsibilities, departmental structure, policies, staff ratios, mis-sion.

Job descriptions (nonemergency department): Issues related to various job descriptions, includ-ing case management, utilization review, transfer center.

Team building: Issues related to interdisciplinary team building and huddles.

Misc.: All other issues (see Figure 3 ).

REFERENCES American Case Management Association. (2010-2011).

National hospital case management survey [Published Results]. Little Rock, AR: Author.

American Case Management Association. (2012-2013). National hospital case management survey [Published Results]. Little Rock, AR: Author.

American Case Management Association . (n.d.). Learn-ing link disclaimer & legal rules . Retrieved March 10, 2013, from http://www.acmaweb.org/section.asp?sID = 10&mn = mn5&sn = sn5&wpg = ll.

American Nurses Credentialing Center . ( 2011 , March). 2010 role delineation study: Nursing Case Manage-ment National Survey results . Silver Spring, MD : Author .

Case Management Society of America . ( 2010 ). Standards of practice . Little Rock, AR : Author .

Case Management Society of America . (n.d.). Defi nition of case management . Retrieved March 24, 2013, from http://www.cmsa.org/Home/CMSA/WhatisaCaseManager/tabid/224/Default.aspx

Staffi ng: Issues related to roles/responsibilities, departmental structure, policies, staff ratios, mis sion.

Software/IT: Issues related to discharge plan ning, case management/utilization review software, elec-tronic medical records, meaningful use, etc.

Team building : Issues related to interdisciplinary team building and huddles.

Misc.: All other issues (see Figure 1 ). Best practice/quality: Standards of care for spe-

cifi c disease states, professional articles, certifi ca-tion, The Joint Commission compliance.

Compliance: CMS-related guidance and regulatory adherence.

Observation: admission status orders, RAC, pre-payment reviews, utilization management plans.

Discharge planning/care transitions: Diffi cult dis charges, discharge assistance programs, dis-charge resources, transfer centers.

Denials: Non-CMS utilization review activity, denial management, criteria.

Physician Advisor/Physician Roles: Issues related to physician advisor, attending physician, medi-cal director roles.

Documentation: Issues related to clinical docu-mentation improvement and other charting issues; Billing : Non-RAC, billing-related issues.

Emergency department : Issues related to emer-gency department functioning, including staffi ng, coverage, job descriptions.

Outcomes: Metrics : Issues related to benchmarking, targets, acuity systems; Information technology/software : Issues related to discharge planning, case management/utilization review software, electronic medical records, meaningful use, etc.

Outpatient: Issues related to outpatient proce-dures, billing, and outpatient staff roles.


Staffi ng: Issues related to roles/responsibilities, departmental structure, policies, staff ratios, mis sion.

Job descriptions (nonemergency department): Issues related to various job descriptions, includ-ing case management, utilization review, transfer center.

Team building: Issues related to interdisciplinary team building and huddles.

Misc.: All other issues (see Figure 2 ). Best practice/quality: Standards of care for spe-

cifi c disease states, professional articles, certifi ca-tion, The Joint Commission compliance.

Outcomes: Issues related to benchmarking, tar-gets, acuity systems; Information technology/software : Issues related to discharge planning,




Muller , L. S. ( 2013 ). Editors commentary . Professional Case Management , 18 ( 1 ), 36 40 .

Phaneuf , M. ( 2008 ). The roles and qualities required of a case manager . Retrieved November 24, 2012, from http://www.infi ressources.ca/fer/Depotdocument_anglais/The_Roles_and_Qualities_Required_of_a_Case_Manager.pdf

Phoenix Medical Management . (n.d.). Best practice con-sulting services . Retrieved March 31, 2013, from http://www.phoenixmed.net/best-practice-consulting-services.html

Powell , S. K. ( 2012 ). The gestalt of case management . Professional Case Management , 16 ( 5 ), 227228 .

Reynolds , J. ( 2004 , July). Case management and discharge planning along the continuum staff presentation . New York, NY : St. Lukes-Roosevelt Hospital .

Smith , A. C. ( 2011 ). Role ambiguity and confl ict in nurse case managers: An integrative review . Professional Case Management , 16 ( 4 ), 182 196 .

Tahan , H. A. , & Campagna , V. ( 2010 ). Case manage-ment roles and functions across various settings and professional disciplines . Professional Case Manage-ment , 15 ( 5 ). Retrieved March 26, 2013, from http://www.nursingcenter.com/prodev/ce_article.asp?tid = 1067978

Wikipedia . (n.d.). Case management (USA health system). Hos-pital case management . Retrieved April 13, 2013, from http://en.wikipedia.org/wiki/Case_management_ (USA_health_system)

John Jude Reynolds, CCM, CPHM, LCSW, has been a CCM since 1996 and a health care manager for 24 years. He has published numer-ous articles for the American Hospital Association and most recently in the American Journal of Nursing. John is currently the Director of Care Management & Patient Access at St. Vincents Medical Center, Westport Campus, Westport, CT.

Center for Medicare Advocacy . (n.d.). Retrieved Septem-ber 8, 2012, from http://www.medicareadvocacy.org/medicare-info/observation-status/

Cohen , D. H. ( 2012 ). Hospital status admission determina-tion: The use of Boolean logic, set theory, and infor-mation theory to improve accuracy . Professional Case Management , 17 ( 6 ), 258 264 .

Daniels , S. , & Frater , J. ( 2011 , August). Hospital case man-agement and progression of care . Healthcare Financial Management , 65 ( 8 ), 108 113 . Retrieved September 8, 2012, from http://www.hfma.org/GSASearch.aspx?id = 4482&searchterms = progression%20of%20care.

Daniels , S. , & Reece , R. ( 2007 ). The business case for hospi-tal case management for health leaders news . Retrieved September 8, 2012, from http://phoenixmed.net/best-practice-consulting-services.html

Entropy . (n.d.). In Merriam-Websters online dictionary . Retrieved March 30, 2013, from http://www.merriam-webster.com/dictionary/entropy

Fry , J. ( 2007 , March 26). All in one? Technology compa-nies dream of one device that can do it all. Now if only consumers would get on board . The New York Times , p. R6 .

Gray , F. C. , White , A. , Brooks-Buck , J. ( 2013 ). Exploring role confusion in nurse case management . Professional Case Management , 18 ( 2 ), 6676 .

HCPro, Inc . ( 2008 ). Observation status: A guide to compli-ant level of care determinations (2nd ed.) . Retrieved September 3, 2012, from http://www.hcmarketplace.com/supplemental/6325_browse.pdf

Health Law and Regulation . ( 2010 ). The changing role of the healthcare case manager . Retrieved September 8, 2012, from http://www.hin.com/sw/healthLaw_regulation122710_case_manager_hospital_discharge_primary_care_ROI_ER.html

Muller , L. S. ( 2012 ). The ever changing legal landscape . Professional Case Management , 17 ( 1 ), 33 36 .

For more than 38 additional continuing education articles related to Case Management topics, go to NursingCenter.com/CE.


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