Part Five: Case Management Boot Camp 2026: Fundamentals for Everyday Practice (PT5W6013)-Basics Case Mgt 2026 Part 5 Presentation

Basics Case Mgt 2026 Part 5 Presentation

Pdf Summary

This presentation explains acute care case management roles, functions, staffing, and care delivery models.

It defines <strong>roles</strong> as the major categories of work case managers perform, and <strong>functions</strong> as the specific tasks within each role. The core roles include: <strong>patient flow/coordination of care</strong>, <strong>utilization and resource management</strong>, <strong>denial management</strong>, <strong>avoidable delay tracking</strong>, <strong>discharge and transitional planning</strong>, <strong>quality management</strong>, and <strong>psychosocial assessment/intervention</strong>.

A major focus is <strong>patient flow</strong>, which includes assessing patients on admission, reassessing daily, participating in interdisciplinary rounds, coordinating tests and treatments, and removing delays so each hospital day is optimized. <strong>Utilization/resource management</strong> ensures services are medically necessary, provided in the appropriate setting, and reimbursable. <strong>Denial management</strong> covers pre-authorizations, appeals, and ensuring documentation supports payer review. <strong>Avoidable delay management</strong> identifies barriers from internal systems, providers, families, patients, or payers. <strong>Discharge/transitional planning</strong> ensures safe, timely movement to the next level of care. <strong>Quality management</strong> tracks adverse events, readmissions, and progress toward outcomes. <strong>Psychosocial work</strong> addresses coping, support systems, financial/housing issues, and complex family or behavioral concerns.

The document compares two staffing models:

- <strong>Integrated model</strong>: RN case managers handle most core functions; social workers support psychosocial discharge planning and complex cases.
- <strong>Collaborative model</strong>: separates clinical case management from business/utilization functions, with different staff roles working together.

Both models require strong leadership, clear role definition, adequate staffing, and strong communication. The presentation also gives staffing ratios, vacancy coverage guidance, and step-by-step processes for RN case managers and social workers, emphasizing that case management is iterative, interdisciplinary, and centered on efficient, safe patient movement through care.

Keywords

acute care case management

patient flow

utilization management

denial management

discharge planning

transitional care

quality management

psychosocial assessment

staffing models

interdisciplinary care