Care Management: Defining Care Team Roles Based on Population Needs

by Tomi Ogundimu on May 30, 2019


Does care management design mean more “boots on the ground” are needed immediately—or not?

Interestingly, many key transformation officers believe the answer to this question is a definitive “yes.” A few years ago, about 97 percent of health system leaders we surveyed were either already investing in or planning to invest in additional care management positions.

However, I would argue that hiring more employees is not truly the solution. To quote one physician network director, “Within one week, a patient could have literally ten people calling her to make sure she’s okay. That is hugely resource-intensive, inefficient and annoying from a patient’s perspective. It winds up turning patients off rather than getting them engaged.”

Obviously, investments must be made in the care management team. But before you start earmarking funds to hire skilled FTEs, pivotal staffing decisions can be reached by first analyzing how current employees spend their time. Such an assessment ensures that defined care team roles are matched appropriately to a population’s needs. 

Thus, this second attribute of five in building an effective modern care management model is the need to define care team roles according to the needs of your patient population. This is clear in the following four opportunities to better scope roles made evident by the Advisory Board’s research and use cases.


1. Gather feedback about ways to improve the care management design process.

LifeBridge Health in Baltimore, Maryland, assembled an inpatient and emergency department (ED) care management redesign team comprised of care managers, social workers, nurses and other healthcare professionals associated with vital care management positions. The new team helped provider leaders accomplish two goals:

  1. Identify the various gaps and redundancies among physicians
  2. Distinguish ownership of care management staff roles through new job descriptions and day-in-the-life summaries, a.k.a. overviews of daily routines, primary duties and activities

Redesigning team roles across the continuum is far from a static process. In fact, LifeBridge Health used town hall meetings to position physician leaders and nurses involved in population care management to communicate changes, secure engagement and encourage feedback to process improvement recommendations over time. Additional meetings ensued to permit team members to share successes and make further refinements to various care management roles.

What was our most profound takeaway in helping providers evaluate internal roles? Even the best design plan still needs to be tested before the day of operation. Performing an audit of day-to-day responsibilities or communication among care management staff, for example, ensures your organization is doing the utmost operationally with current resources.


2. Split discharge planning between inpatient roles to support collaboration.

The Advisory Board’s research uncovered another important finding of care management program assessments: inpatient case management staff—usually a combination of social workers and registered nurses (RNs)—who have worked together on the same care team tend to collaborate exceptionally well.

Why is this important? When health systems implement a traditional triad care management model, social workers—certified to care for complex patients with psychosocial needs—are often underutilized managing these patients. Instead, our assessments found that social workers spend most of their time on referral coordination and some discharge planning tasks. 

Since discharge planning has grown increasingly complex, many progressive provider organizations have now moved to a new triad model for inpatient case management. In that triad model, RN functions are separated from the case management role. Case managers can then focus their time on clinical discharge planning, care coordination and patient management.

Further, social workers may partner with RNs and case managers in facilitating the discharge planning process for complex patients with higher psychosocial needs, ensuring these hard-to-place individuals receive the appropriate advocacy when transitioning to the skilled nursing facility (SNF) network.  

In some instances, the social worker and the case manager (an RN) collaborate on issues using their natural instincts to work together, employing their respective areas of expertise to increase efficiencies and interventions.

To that end, coordination and communication between these two team members is critical in any type of triad model for case management focused on a target population. 



3. Offload clerical functions to support staff.

In 2010, the University of Wisconsin Hospitals and Clinics (UW Health) underwent a large-scale care management redesign to make utilization review (UR) a system-wide, rather than hospital-based, function. The organization further wanted to create a specialized resource management center (RMC) to facilitate SNF referrals and book post-acute care discharge ambulances.

During the redesign effort, 26 new operational workflows were created to outline how geographically oriented, unit-based care coordinators would interact with the various UR nurses in the newly formed RMC.  Initially, UW Health’s RMC was staffed by three referral specialists and two payer specialists who handled case management functions, such as assisting with arranging patient transportation, payer contracting, and data and outcomes analysis.

Clerical staff members were later added to UW Health’s resource management center to offload even more discharge tasks from the care coordinators’ responsibilities. The move from a triad to an inpatient care management model in recent years has made many large health systems think differently about increasing the bedside time between case managers and patients—and allocating non-license support staff to daily administrative tasks.    


4. Assign social workers to high-risk patients to aid in workflow management.

Provider leaders must be explicit in identifying the right patients for management by social workers.

Social workers often work with a subset of high-risk patients who may require lengthier episodes of care coordination. Criteria for social worker referrals generally include both psychosocial and complex medical triggers, and each of these require increased patient support.

Depending on the patient’s needs, social workers may provide either a short-term intervention or manage a patient for a longer period. As a result, the Advisory Board found that the social worker’s caseload may tend to fluctuate, whereas case managers who follow all patients tend to work a more fixed caseload. It’s imperative that hospitals determine who will be assigned higher acuity patients and when those assignments will occur. In doing, it becomes easier to manage workflows and better analyze workload among all care management staff.

Determine Criteria for Inpatient Referrals-graphic


Put Your Plan Into Action

Matching your care team to the needs of your patient base is a critical step that can’t be overlooked in the creation of a modern care management model. By taking the time to evaluate your needs and those of your patients and assigning roles accordingly, you’ll be able to maximize your current staffing resources while simultaneously improving the patient experience for those who demand a greater degree of hands-on management.


This article is Part 2 in a series of blogs releasing in the coming months from the Advisory Board's Tomi Ogundimu. You can view Part 1 here and Part 3 here.

Want more of Tomi's expert insights? Read all about the third attribute of a modern care management model here, or view the "Getting the Most Out of Your Care Management Model" webinar now!


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Meet the Author

Tomi is the practice manager of Population Health Advisor, a custom project-based membership offering strategic guidance and best practices on the transition path toward population health management. In this capacity, she works with population health and care transformation leaders on a wide range of topics including developing an integrated care management model, measuring the ROI of their interventions, care delivery innovation, post-acute care network development, and patient engagement. Prior to joining the Advisory Board, Tomi worked as a health policy consultant for the Center for Healthcare Research and Transformation—a non-profit partnership of the University of Michigan and Blue Cross Blue Shield of Michigan—where she gained expertise in a range of health policy issues. Tomi graduated from Michigan State University with a bachelor of science in human biology and holds a master of public health in health management and policy from the University of Michigan.