HLTH 3105 Week 2 Professional Role Seam Analysis Example

The Seam Between Nurse Case Manager and Hospital Social Worker in Discharge Planning: Overlapping Work, Unowned Tasks and Where Each Scope Begins

Student Name

Walden University

HLTH 3105: Interprofessional Teamwork in Healthcare

Instructor Name

Month Day, Year

The Seam Between Nurse Case Manager and Hospital Social Worker in Discharge Planning: Overlapping Work, Unowned Tasks and Where Each Scope Begins

Why Look at the Seam

Two job descriptions placed side by side make two professions look neatly separate. On the medical unit where I work, the nurse case managers and the hospital social worker both plan discharges, and the work does not divide as neatly as their descriptions suggest. This paper looks at the seam between them: the zone where they do overlapping work, the tasks neither one clearly owns and what published professional standards say about where each scope begins. The unit is described from my own observation and is not identified. The aim is not to decide which profession is more important but to find where work falls between them, because that is where patients wait.

What Each Profession Says Its Scope Is

Nurse case managers. The Case Management Society of America's standards describe case management as a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet a person's health needs (Case Management Society of America, 2022). On our unit, the nurse case managers are registered nurses. Their scope, in practice, centers on the clinical side of discharge: confirming the medical plan, arranging skilled services such as home health, coordinating with insurers for authorization and ensuring the patient's level of care after discharge matches clinical need.

Hospital social workers. The National Association of Social Workers' standards for health care settings describe social workers as addressing the psychosocial, economic and environmental factors that affect health, including assessment of family and social support, counseling, advocacy and connection to community resources (National Association of Social Workers, 2016). On our unit, the social worker is called for patients with complex psychosocial needs: unsafe housing, caregiver conflict, suspected abuse or neglect, guardianship questions and placement in long-term care.

What the federal rule requires. Medicare's hospital rules call for a working discharge planning process that spots patients who will need help after leaving, assesses that need and sets up the help, yet the rules do not assign the work to a particular profession (42 C.F.R. § 482.43). The division of labor is left to each hospital.

Where the Work Overlaps

Three tasks are done by both professions on our unit, depending on who reaches the patient first.

Assessing home support. The case manager's initial assessment asks who lives with the patient and who can help after discharge. The social worker's psychosocial assessment asks the same questions in more depth. Patients sometimes answer both, on the same day, and give slightly different answers.

Arranging placement in a skilled nursing facility. Case managers send referrals to facilities when skilled care is clinically indicated. Social workers become involved when the patient or family resists placement, when finances are complicated or when long-term placement may follow. In practice both send referrals, and a facility sometimes receives two calls about one patient.

Talking with families about the discharge plan. Both professions call families. When the plan is simple, the case manager calls. When the family is upset or the plan is contested, the social worker calls. But the line between simple and contested is drawn case by case, often after the first call has already gone badly.

How Patients Experience the Seam

Patients do not see professional scopes. They see two people with similar badges asking similar questions, and they often cannot tell which one to call when something changes. On our unit, families have told me they repeated their whole story to the social worker after telling it to the case manager that morning, and that they were not sure which of the two was in charge of finding a nursing home. One daughter received two different estimates of when her father could leave, one from each profession, because each was working from a different version of the plan.

These experiences matter beyond courtesy. Families who are unsure who is responsible are less likely to raise a problem early, such as a change in who can drive the patient home, and that delay feeds the unowned tasks described below. Clear ownership is partly about efficiency, but it is also about giving patients and families one reliable point of contact at a stressful time.

Tasks Neither One Owns

More troubling than the overlap are tasks that fall outside both scopes as practiced on the unit.

Confirming that equipment actually arrived at home. The case manager orders home oxygen or a hospital bed and confirms the vendor accepted the order. Nobody calls the patient on the day after discharge to confirm the equipment arrived and works. Neither profession's standard excludes this task, but neither job description on our unit includes it.

Reconciling transportation with discharge time. Whether a patient has a ride home at the planned time is asked by the case manager at admission and by the bedside nurse on the day of discharge. If the answer changes in between, nobody owns updating the plan, and the patient waits in a chair for hours.

Following up when a referral is declined. When a skilled nursing facility declines a patient, the case manager learns of it, but if the reason is psychosocial, such as a family member the facility considers difficult, the social worker may never hear, and the next referral repeats the same problem.

What a Clearer Seam Would Look Like

A clearer seam does not require rewriting either profession's scope. It requires the unit to decide, in writing, three things. First, a single trigger for social work involvement, such as any patient with a positive screen on a short psychosocial checklist completed by the case manager at admission, so the line between simple and complex is drawn once, early, by a rule. Second, one owner for each of the unowned tasks: for example, the case manager owns the day-after equipment call and the transportation check the evening before discharge, while the social worker is copied on every declined placement. Third, a shared note in the record that both professions update, so families are not asked the same questions twice. Research on interprofessional collaboration suggests that practice-based changes of this kind, clarifying routines and communication rather than relying on goodwill, are among the more promising approaches, though the evidence is still developing (Reeves et al., 2017).

The seam will never disappear. Two professions with overlapping concern for the same patient will always share some territory. The goal is to make the shared territory visible and the unowned tasks owned.

References

Case Management Society of America. (2022). Standards of practice for case management. https://cmsa.org/sop22/

Condition of participation: Discharge planning, 42 C.F.R. § 482.43 (2024).

National Association of Social Workers. (2016). NASW standards for social work practice in health care settings. https://www.socialworkers.org/practice/standards-guidelines

Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 2017(6), Article CD000072. https://doi.org/10.1002/14651858.CD000072.pub3