Understanding Care Coordination: Emerging Opportunities for Social Workers

With the passage of healthcare reform legislation in early 2010, care coordination continues to attract national attention as an important component of service delivery to achieve quality, efficiency, and efficacy goals. Indeed, the Patient Protection and Affordable Care Act has elevated care coordination as an important means to serve a wide variety of patients with particular needs, such as the frail elderly and those with pre-existing and chronic conditions, including many who until now did not have access to healthcare coverage. Care coordination is being hailed as a way to help patients navigate what is often a fragmented and inefficient process.

For social workers, the question then becomes: how do we as a profession find our place within a care coordination role? The purpose of this article is to inform social workers about the many facets of care coordination, including why it is seen as key to both improving the delivery of care and treatment and preserving scarce and costly resources. It will also offer social workers points of reflection to appreciate how the potential of care coordination can only be realized with professionals who understand the importance of values such as patient self-determination, which is a cornerstone of practice for social workers. Further, social workers, and in particular those who are in case manager roles, should realize that their particular skills and expertise will be sought as part of transdisciplinary teams across the healthcare continuum.

Care coordination, which encompasses case management and care management, involves direct clinical interventions delivered to individuals. According to the National Quality Forum (NQF), “Care coordination helps ensure a patient’s needs and preferences for care are understood, and that those needs and preferences are shared between providers, patients, and families as a patient moves from one healthcare setting to another. Care among many different providers must be well-coordinated to avoid waste, over-, under-, or misuse of prescribed medications, and conflicting plans of care” (NQF, 2010). Thus, care coordination is seen as especially important for people with chronic or complex conditions who receive care in multiple settings from numerous providers.
Care coordination is also seen as addressing the systemic problems within the healthcare system, as highlighted by the Institute of Medicine in its groundbreaking 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century.” The report identified problems such as a lack of coordination within the delivery system, fragmentation that slows care and undermines accountability, poor communication and use of information technology, and failure of health care professionals to work together to ensure that care is appropriate, timely, and safe (IOM, 2001).

Overall, care coordination must be patient-centered and accessible and take a transdisciplinary approach. It must address the needs of patients: from a multi-dimensional lens of biophysical, psychological, sociological, and spiritual assessment. The focus is on providing appropriate and consistent access to care, while empowering patients as they navigate transitions.
Across the healthcare spectrum, care coordination is being implemented and evaluated as part of the foundation of new models for delivery of care and treatment, including the patient-centered medical home and accountable care organizations. As these models (which will be defined later in the article) expand in usage, social workers must become involved, along with other practitioners from a variety of professional disciplines. To take their place at this table of opportunity, social workers need to be conversant in the language of care coordination, and assess how their skills and expertise in areas such as “goodness of fit” lend themselves to pursuing the goals of improving quality, efficiency, and efficacy of healthcare.

Opportunities for Social Workers
Simply put, care coordination is not only for nurses. Indeed, the latest reports on care coordination highlight the importance of a transdisciplinary approach, bringing together a variety of disciplines to meet the health and human services needs of patients. Because these needs are often complex, no one profession can be expected to meet them all. Thus, by working together in a transdisciplinary environment, social workers, nurses, and other clinicians bring the best of their practices to improve the delivery of care to patients. This is the essence of care coordination.

Consider the March 2009 report, The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses, commissioned by the National Coalition on Care Coordination (N3C). The report found that care coordination “can reduce hospitalizations and Medicare costs and improve quality of care for chronically ill older adults—provided the programs: promote direct engagement of teams of primary care physicians, nurses, and social workers; create close communication among all providers involved in a patient’s care; and empower patients to help manage their own care.”
The report also highlighted several components that should be included in care coordination. Among them are a “multidisciplinary team approach to care that assigns a nurse as care coordinator, directly engages the primary care physician, addresses hospital transitions, and includes social workers to coordinate and help arrange community services for patients who needs them.” The report also recommended that interventions be targeted to patients who will most benefit, and involve in-person, “high touch” contact between the patient and care coordinator (NYAM.org).

Social workers are already taking part in care coordination. For example, Harvard University Health Services’ Care Coordination Department addresses the medical and psychosocial needs of patients and their families/support systems by “facilitating access to appropriate levels of care and services.” The department takes a transdisciplinary approach and is staffed by a nurse case manager, a social worker, and a durable medical equipment coordinator (Harvard University Health Services, 2010).

Given the importance of care coordination and the high expectations for achieving its goals, services must be delivered by competent, credentialed professionals who possess the necessary and proven knowledge, skills, and expertise. Certified case managers who come from a variety of disciplines, including social work, nursing, occupational therapy, mental health counseling, and others, are uniquely positioned to serve as care coordinators. The Commission for Case Manager Certification (CCMC) is the first and largest nationally accredited organization that certifies multi-disciplinary, clinically trained case managers. The CCMC defines case management as “a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client’s health and human services needs.” Case management is “characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes” (Commission for Case Manager Certification, 2010a).

Thus, licensed and credentialed professionals such as social workers who practice case management as an advanced practice are able to showcase their knowledge and expertise, particularly within the transdisciplinary environment called for in care coordination. Attaining the Certified Case Manager (CCM) credential enables the social worker case manager to attest to his or her education and experience through an evidence-based examination and mandatory continuing education. A valid and thorough credentialing process such as CCM certification also increases the likelihood that a professional—whether a social worker, nurse, or other practitioner—possesses competencies needed to pursue care coordination goals and create the necessary synergy within diverse, transdisciplinary teams of health and human services professionals.

Consider the CCMC’s “Philosophy of Case Management,” which highlights the pursuit of “client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation.” As the CCMC further states, “Based on the needs and values of the client, and in collaboration with all service providers, the case manager links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable….” (Commission for Case Manager Certification, 2010b).
This language is congruent with the Code of Ethics of the National Association of Social Workers, including the ethical principle of respecting the “inherent dignity and worth of the person.” Specifically, the principle obliges social workers to “treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients’ socially responsible self-determination…” (National Association of Social Workers, 2008).

The emphasis on self-determination within social work highlights the contribution our profession can make to care coordination in pursuit of patient-centered care. This is especially important as new models of care are pursued for the delivery of health and human services to patients. These new models include:

  • Patient-Centered Medical Home—encompassing multiple venues, such as primary clinics, community mental health center, adult day care center, nursing home, or other long-term care facility. A medical home is anywhere a person might routinely access first-line care and treatment. The patient-centered medical home is seen as improving outcomes while lowering healthcare costs. Importantly, a medical home is not considered to be complete without a mental health component, which highlights the importance of social work involvement.
  • Accountable Care Organizations—bringing together hospitals and provider groups to support evidence-based healthcare, quality and costs, and coordinated care.
  • Guided Care—for the delivery of comprehensive, coordinated, and patient-centered care for patients with chronic conditions.

Social workers should also be part of efforts to improve health literacy, which requires a transdisciplinary approach to improve patients’ understanding, and thus their ability to adhere to physicians’ orders. Health literacy has been identified by the Joint Commission on Hospital Accreditation as a major focus in its landmark 2007 white paper, What Did the Doctor Say, Improving Literacy to Protect Patient Safety (Joint Commission, 2007). Improving health literacy is directly linked to decreasing the barriers within the health system that lead to communication breakdowns and medical errors.
To participate in new opportunities, social workers need to educate themselves about these emerging models of care delivery and pursue how they can contribute their expertise in psychosocial aspects of care and obtaining community resources to support the patient.

Discover Your Competencies
Social workers, and in particular social worker case managers, will find new opportunities to engage in the dialogue to contribute their expertise to care coordination initiatives. For this to happen, social workers need to empower themselves to discover their own competencies and showcase them to others. This involves some “out-of-the-box” thinking beyond the traditional roles of social work, in order to:

  • discover your strengths,
  • be proactive rather than reactive in your career, and
  • merge your professional self with identified professional opportunities.

With the expected growth for social work and case management in the coming years, it is time for every practitioner to consider: What are my unique skills and where will they best fit?
The following 4-step exercise is designed to help you identify and appreciate the array of skills and competencies that you have to offer.

Identify 10 skills and/or competencies you currently possess that will be most valued by the future job market. Your list may include such things as professional values, ethics, competencies, and skills.
Rate each in the order of importance, with 1 being the most essential and 10 the least.
Identify five skills/competencies that would further enhance your marketability.
Ask yourself: How would you obtain those specific skills/competencies?

Change on the Horizon
Given the tremendous amount of change in the field of health and human services in the era of healthcare reform, social workers must be prepared. It begins with awareness and education to understand the challenges as well as the opportunities presented by healthcare reform and by approaches such as care coordination. Admittedly, such a change in perspective can be difficult. However, social workers need not feel limited by the options. With awareness comes empowerment to think where you, as a social worker, want to be and then to advocate for yourself to get there.

Care coordination is in the spotlight as a desired means to improve the quality, efficiency, and efficacy of healthcare. Now, social workers need to let that light shine on them as well, highlighting their expertise, knowledge, skills, and competencies as practitioners who must be part of transdisciplinary teams across the health and human services continuum. The more social workers are prepared by educating, empowering, and advocating for themselves, the more they can find new opportunities in the era of healthcare reform with a greater emphasis on care coordination.

Written By Ellen Fink-Samnick, LCSW, CCM, CRC


Commission for Case Manager Certification. (2010a). Definition of case management. Retrieved September 16, 2010 from http://www.ccmcertification.org/secondary.php?section=Case_Management.

Commission for Case Manager Certification. (2010b). Philosophy of case management. Retrieved September 16, 2010 from http://www.ccmcertification.org/secondary.php?section=Case_Management.

Harvard University Health Services. (2010). Care coordination. Retrieved September 16, 2010 from http://huhs.harvard.edu/OurServices/CareCoordination.aspx.

Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the  quality chasm. Washington, DC: National Academy Press.

JointCommission.org. (2007). What did the doctor say. Retrieved from http://www.jointcommission.org/NR/rdonlyres/F53D5057-5349-4391-9DB9-E7F086873D46/0/health_literacy_exec_summary.pdf.

National Association of Social Workers. (2008). Code of ethics of the National Association of Social Workers, ethical principles. Retrieved September 16, 2010 from http://www.naswdc.org/pubs/code/code.asp.

National Quality Forum. (2010). Endorsing preferred practices and performance measures for measuring and reporting care coordination, Overview. Retrieved September 16, 2010 from http://www.qualityforum.org/projects/care_coordination.aspx?section=PublicandMemberComment2009-10-26#t=1&s=&p=.

New York Academy of Medicine. (2009, March 13). Promise of care coordination. Retrieved from http://www.nyam.org/news/3208.html#.

Ellen Fink-Samnick, LCSW, CCM, CRC, is a former Commissioner of CCMC and past Chair of the Commission’s Ethics and Professional Conduct Committee. She is president of EFS Supervision Strategies, LLC in Burke, VA, and has 27 years of experience developing innovative case management models for health and mental health care. She also serves as adjunct faculty for George Mason University’s College of Health and Human Services.

*Reprinted with permission of the publisher from The New Social Worker Magazine at: http://www.socialworker.com/home/index.php

The original article can be found at: http://www.socialworker.com/home/Feature_Articles/Professional_Development_%26_Advancement/Understanding_Care_Coordination%3A_Emerging_Opportunities_for_Social_Workers/

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