By Tiffany Ferguson, LMSW, CMAC, ACM 

I feel compelled to address the recent inquiries circulating on social media regarding the professional ownership of initial assessments in case management. The idea of whether this responsibility could be delegated to a supportive employee for information collection has sparked contemplation and, in turn, motivated me to share these thoughts. 

In our journey towards exceptional case management, it's crucial to move beyond mere task-driven discharge needs and embrace a collaborative process between patients and the care team. The role of case management (CM) professionals, whether RNs, social workers, or other healthcare allies, is crucial in identifying patients who genuinely need their support through consults, independent screening, or the application of technology algorithms in the EMR.  

It's imperative to emphasize that case management documentation should transcend a mere 'to-do' list of tasks towards patient discharge. The initial assessment should not be a sparse expansion of the patient demographic sheet. Once a patient is identified as needing case management services, the documentation must reflect a comprehensive assessment conducted by the CM in collaboration with the patient. This goes beyond the information obtained from the medical team, including attending H&P and initial nursing documentation. The initial assessment thus becomes the cornerstone as a proactive step for CMs to lay the groundwork for the care progression and transition of the care process. This is not a routine checkbox exercise; it's an opportunity to engage authentically with the patient, their family, or representatives, building a foundation of trust for the journey towards discharge. 

Without delving into a full outline of a great CM initial assessment, the main focus areas should include the pre-hospital home environment, patient support understanding of prior functioning levels, incorporation of key decision-makers, consideration of Social Determinants of Health (SDoH) risk factors, and identification of any factors impacting the patient's access to or management of medical care. Additionally, the initial assessment should discuss the anticipated care plan for transition, addressing potential steps and barriers to its success. 

Ongoing notes, especially the final note confirming the discharge plan, should serve as the conclusion to the story. This documentation must meet the requirements for Conditions of Participation Discharge Planning (§482.43 CoP: Discharge Planning), such as patient choice and the integration of patients and/or family in the care planning process. Patient disposition should be identified, specifying whether the patient is returning to a custodial nursing home or obtaining skilled nursing care. Documentation should also address the resumption of pre-existing home health services or any new arrangements due to hospitalization. Expedited start dates for post-acute arrangements should be clearly outlined. 

While the use of EMRs with dropdowns and shared fields for collaboration is encouraged, adherence to the principles remains crucial— If it was not documented it was not done and it should concisely depict the needed information for the intended audience.   

Join us in Nashville for CMSA Case Management Boot Camp, March 8-10! Don't miss this unique opportunity to start strong in case management, learn about other CM practice areas, or get back to basics. Explore ethical practices, healthcare reimbursement, versatile skill sets, communication techniques, and more as you earn 19.5 RN, SW, and CCM CEs over two and a half days of in-person instruction with group discussion, interactive exercises and case studies. Deadline to register is March 1. Space is limited!

Bio: Tiffany Ferguson, MSW, ACM, CMAC is CEO of Phoenix Medical Management, Inc. Tiffany serves as an adjunct professor at Northern Arizona University, Department of Social Work, and on the American College of Physician Advisors (ACPA) Observation Subcommittee. Tiffany is co-author of The Hospital Guide to Contemporary Case Management through HcPro. She is a contributor for RACmonitor and Case Management Monthly; she also serves on the editorial board for CMSAToday and Care Management. She is a weekly correspondent on SDoH for the news podcast Talk Ten Tuesday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles in Health & Care Management, which includes CM, UR, CDI, HIM, and coding. She has held C-level responsibility for a large employed medical group which included value-based arrangements and outpatient care management. Tiffany is a graduate of Northern Arizona University and received her MSW at UCLA.