Case Management Corner: Why Are Case Managers Using The Same, Tired Framework?

By Kelly Bilodeau

Today’s case managers have digital tools, value-based goals, and post-pandemic challenges. So why are they still relying on a 1990s playbook?

For decades, hospitals have used the Triad Model: a case manager, social worker, and utilization review specialist committed to getting the patient out of the hospital as quickly and efficiently as possible, according to Marie Stinebuck, MBA, MSN, ACM, COO at Phoenix Medical Management Inc. However, as patient complexity rises, staff numbers shrink, and goalposts shift, this three-legged structure is buckling under modern demands, said Tiffany Ferguson, LMSW, CMAC, ACM, CEO of Phoenix Medical Management.

 It’s time for a new framework—the Adaptive Model, which Ferguson recently outlined in an article for CMSA Today.

Navigating post-COVID challenges

Many hospital officials recognize that the Triad Model is a problem, Ferguson said in a recent Finally Friday webinar.

“People are coming to us saying, ‘We need to look at this model. I don't think we have the right staffing mix,’” she said.

Job responsibilities feel muddled. Case managers and social workers often have overlapping responsibilities, which creates redundancies and confusion for patients. The Utilization Review (UR) role evolved significantly during COVID, as many positions transitioned to remote work. This shift altered the dynamics and collaboration within the inpatient care team. These factors put a drag on efficiency in a department that is already often understaffed and overburdened following a surge in pandemic-driven retirements.

At the core of these issues is an outdated system, way overdue for an update.

“Until readmissions became a key focus around 2012, case management remained primarily centered on discharge planning," Stinebuck said.

Since that time, hospitals have adopted integrated technology, including automated workflows and AI-driven case management software, and added post-acute partners. However, the foundational model hasn’t caught up.

Moving to a new approach

Where the Triad Model falls short in promoting proactive pre-hospitalization planning or addressing the social needs of patients, the Adaptive Model excels. It helps to eliminate redundancies between case management and social work.

“This new Adaptive Model looks at those roles. How do we complement each other without overlapping and work in the best interest of that patient?” Stinebuck said.

It also expands the tent, incorporating new team members, such as the physician advisor, a position formalized after the Triad Model’s inception, and non-licensed professionals. These non-licensed staff members reduce the burden on case managers by handling routine administrative tasks like scheduling outpatient appointments, arranging transportation, and delivering regulatory notices. This frees case managers to focus on more critical aspects of patient care and new goals, such as readmission prevention, addressing social determinants of health, and meeting value-based care targets.

The Adaptive Model also recognizes the time-saving value of integrated technology and expands interventions beyond inpatient units. Care has changed. The Adaptive Model follows patients into the emergency department, pre-surgical and hospitalized outpatient units, and even into their homes using telehealth.

Making the shift

Now, the goal should be to make changes that help case management meet patient needs in a world where efficiency is more crucial than ever. Case management no longer starts and ends in the hospital. Planning begins before admission, extends after discharge, and goes beyond simply pushing people through the system. The Adaptive Model is patient-centered and offers case managers the tools and the bandwidth to meet their needs at a time when demands often outstrip resources.

The old model is costing hospitals “time, money, and sanity,” said Ernie de los Santos, host of the Finally Friday webinar. It’s time to transition. The shift to the Adaptive Model isn’t just an evolution, “it’s a survival strategy,” he said.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.