By Tiffany Ferguson, LMSW, CMAC, ACM

I can remember when the movement of coordinating the progression of care became the hot topic for acute case management; suddenly, we moved from discharge planners to care coordinators with new titles and new models. It was around 2010 and I was working as a frontline social work case manager in my regional health system. The caseload then of 30 plus patients seemed overwhelming as I made the transition from a CM doing strictly discharge planning to care coordination. I was now expected to prepare for this thing called “interdisciplinary rounds” with the physicians and understand the patient progression of care. Our job descriptions were updated and training was completed, but a true transformation took years as we fine-tuned our art of case management in an evolving value-based healthcare landscape. I was expected to proactively screen my patients who were high risk and assess for resource utilization, ensure progression of care, and since 2012, make sure my patients had a safe transition to avoid readmission.

I wish I could say that this movement caught on like wildfire across hospital systems; however, now after we have been short-staffed and a bit shaken from the trauma of COVID, I have seen a loss of coordinating care and a return to just discharge planning. I am pained to see such regression; however, understand that many case management programs are still struggling with staffing. They are managing large caseloads or dealing with the continued turnover of travelers. Nurses and social workers are rotating as some trickling out of the system into remote work or retirement as the new green staff are coming in. This leaves leadership at a perpetual disadvantage unable to advance practice and instead stuck in managing schedules and assignments.

Settling into a new case management story:

So now in our new era, how do we ensure safe transitions while also supporting the progression of care and addressing the impact of our patients’ social determinants? How can we apply our critical thinking skills and ensure we appropriately support and advocate on behalf of our patients?

I think we start with the end in mind. How do we want to be envisioned to our patients and our stakeholders (physicians, nursing, etc.)? And then, we work backward. Remember, the discharge planner is simply acting on the care teams’ plans and suggestions continuingly in a responsive position. However, the care coordinator is identifying and contributing to the care team with suggestions and advice. Ideally, the case manager can spend time with their patients completing thorough assessments early in the hospitalization. They can provide helpful information and insight to support and advocate on behalf of the patient’s needs to ensure the right care, at the right place. They can effectively communicate these insights to the care team, the patient, and the post-acute and community partners. They are seen as the resource that time and time again prove their worth to physicians, nurses, and patients as an organizational staple “they could not live without.” However, to accomplish some of these things, I would say we need to let go of some of our old selves and consider a version for the future.

This means we cannot do it all! 

There is a reason, when the hospital is full, that everyone is looking at the case managers to figure out why the patient has not left yet.  It is because the assumption is that it is solely the case manager’s role to create a discharge plan and thus complete the tasks to get the patients out the door. Historically, it was; however, in the last 30 years, we have evolved and so should hospital staff’s perspectives. A patient’s progression of care is everyone’s responsibility and must be coordinated as such. Thus, case management must relinquish themselves from being involved in every patient and save their skill for those that are more complex. That means they must screen early in the admission and articulate clearly to the care team which patients can be discharged by nursing versus who require the complexity of the case manager or social work consultation. Additionally, they must be willing to relinquish the tasks that do not require a professional license and ensure there is support staff to handle those tasks. I always remind my nurses and social workers that we did not get advanced degrees to arrange rides or make follow-up appointments. Now, in a pinch, any member of the team should lend a hand; however, the system should not be designed for the case manager to be the tasker of discharge logistics. There are too few resources, and our time must be spent on more critical work.

Now is the time, and in honor of our 2022 Case Management Week theme, we should discuss at our staff meetings and within our departments: How do we elevate our case management programs and rebrand ourselves in our hospitals for the future, “Setting the standard for patient-centered care”?

Bio: Tiffany Ferguson, LMSW, CMAC, ACM, is CEO of Phoenix Medical Management, Inc., the case management company. Tiffany serves as an adjunct professor at Northern Arizona University, Dept. of Social Work and on the ACPA Observation Subcommittee.  She serves as the SDoH specialist on the weekly news podcast, Monitor Monday.  After practicing as a hospital social worker, she went on to serve as system Director of Case Management. Tiffany is a graduate of Northern Arizona University and received her MSW at UCLA.

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