Evolution of Case Management: Moving Beyond the Triad Model
By Tiffany Ferguson, LMSW, CMAC, ACM
Note: This article appears on CMSAtoday’s website at CMSA Today (CMSQ) - Issue 4, 2025 - The Evolution of Hospital Case Management: Moving Beyond the Triad Model.
Hospital case management programs have long relied on the triad model, a structure that includes nurse case managers, social workers and utilization review specialists. While this model served a clear purpose in the late 1990s and early to mid-2000s, changes in healthcare demands, hospital throughput challenges and technological advancements have made it less effective. Today, the complexity of patient care, increasing patient volumes and the need for streamlined care transitions require a revised approach. Many hospitals across the country are feeling the impact of this shift, as the traditional structure no longer aligns with the demands of current patient and hospital needs and limited staffing resources.
Some programs have already begun to evolve beyond the triad model but have yet to clearly define or brand this new approach. Enter the Adaptive Model: a post-COVID framework that recognizes the staffing changes, the importance of social determinants of health, our mental health crisis and the needs of an aging baby boomer population. This model acknowledges that patients are simultaneously socially and medically complex. The Adaptive Model integrates non-licensed professionals as key team members, leverages technological advancements and expands the focus from unit-based inpatient care management to emergency department (ED), pre-surgical and hospitalized outpatient populations. It also marks the movement of utilization review from the traditional case management structure to a revenue cycle framework, deserving its own place on the professional stage.
The triad model was designed to optimize patient care by coordinating medical, social and financial aspects of a patient’s hospital stay. In this model, the nurse case manager focuses on discharge planning, the social worker provides psychosocial support and the utilization review specialist (typically a nurse) ensures medical necessity and appropriate resource utilization. Although these are vital and imperative concepts, there are several inefficiencies that have emerged in the siloing of these functions in today’s current landscape. The most significant issue is redundancy and role overlap, which creates confusion between the demands for the case manager versus the professional licensure that one holds in the current employment marketplace. It is common practice now to see nurse case managers and social workers performing the same role and simply "splitting the unit" as the functions of case management in the acute care setting require a divide and tackle approach to address patient progression of care. The triad model, while historically effective, has several inherent limitations:
Redundancy and Role Overlap: Case managers, social workers and utilization review specialists often perform overlapping tasks, leading to inefficiencies in discharge planning and communication. This fragmentation causes confusion among patients and providers about the roles of different team members.
Unit-Based Structure Limitations: The traditional model prioritizes inpatient hospitalized patients. This approach fails to address the increasing number of patients who require complex transitional planning before formal hospitalization or surgery.
Failure to Recognize the Physician Advisor(s): Although physician advisors were not formally recognized until after the triad model was established, their oversight and function to the team has changed the programmatic design for the care management model. Physician advisors may have dynamic roles with utilization review, documentation integrity and addressing continued stays that are not medically necessary.
Limited Use of Non-Licensed Professionals: Similarly, the model fails to recognize the expansion of job functions to non-licensed professionals. The model hinders the evolved ability for professionals to work top of license due to the logistical demands of the role, reducing the time they can spend on high-value patient interactions.
Inadequate Technology Utilization: The model was created before the advancement of post-acute platforms, machine learning and automation. Many of the functions that require manual chart review can be more efficiently performed through technology support systems, changing the role for non-licensed and licensed team members.
Insufficient Focus on Patient Throughput: Although originally designed to support patient progression of care, the triad model was designed from a unit-based case management perspective. With rising emergency department volumes and an increasing emphasis on outpatient care, hospitals now require a model that emphasizes proactive care coordination before inpatient admission and well after the patient hospitalization under a more value-based/ population health structure.
Social Determinants and Patient Complexity: With new social determinants of health (SDoH) requirements and the rise of patient social complexity leading to greater social admissions, case management departments are forced to evolve and develop creative roles and specialized roles for social workers to tackle this population. Through time, this has also led to expansion of specialized case management roles for unique hospital populations such as palliative, oncology and obstetrics, to name a few.
The Shift of Utilization Review to Revenue Cycle: Utilization review (UR) has increasingly moved out of the case management structure, depending on hospital size, as its own program as a result of payer demands and a stronger focus on medical necessity and denials prevention. This greater alignment with revenue cycle does create some shifts for the traditional case management model, as many utilization review nurses are working remotely, handing some of the functions back to the case managers. This change, likely an article on its own, means utilization review is also changing away from a unit-based model to a functional model to evaluate patients across review and payer needs, leveraging technology for greater workflow efficiency.
The Adaptive Case Management Model
To address these inefficiencies, hospital case management must recognize the already in motion transition to a model that prioritizes:
The Inclusion of Non-Licensed Professionals
A Staffing Structure Focused on Technology and Skilled Communication
A Shift Away from Unit-Based Case Management
A key component of the new model is the strategic use of non-licensed professionals, such as case management assistants, patient navigators, care coordinators, community health workers, etc. These individuals are integral to the success of case management departments and require their own training and professional support to acknowledge the vital role they are serving to facilitate care transitions and support post-acute care services (McLoughlin-Davis, 2019). These individuals range from high school education, the patient care technicians, to associate and bachelor’s degree professionals who can support a wide variety of functions in the case management department. Now more than ever, these individuals are filling gaps in case management programs to address significant nursing shortages across the country. Some of the important services they provide include but are not limited to:
Scheduling follow-up appointments
Coordinating durable medical equipment (DME) and home health services
Arranging transportation
Completing insurance and financial paperwork
Following up on post-emergency room and post-acute referrals
Coordinating outpatient care services
Providing resources for social determinants of health
Delivering regulatory notices
Research has shown that leveraging non-licensed staff in discharge planning improves efficiency and allows licensed professionals to focus on clinical decision-making. By integrating this workforce, hospitals have significantly improved discharge times and reduced readmission rates (AHRQ, 2021).
The Adaptive Model recognizes the requirement for technology to enhance case management efficiency. Some of the key technological advancements now include automated workflows, telehealth and optimization of our electronic medical records. AI-driven case management software can help identify patients needing case management intervention earlier in their hospital stay (Garrett, 2024). Virtual discharge planning and follow-up visits improve post-discharge care coordination. Standardized documentation and decision-support tools improve communication among case management teams.
By leveraging these technologies, the role of case managers, whether nurses or social workers, becomes more focused on high-value clinical decision-making, while non-licensed staff and technology handle many of the administrative tasks. The model also shifts away from tenure as a measure of success, instead requiring a workforce with strong communication, technology and problem-solving skills to facilitate better interactions with medical teams, patients and outpatient providers.
Instead of adhering to traditional unit-based case management, the Adaptive Model acknowledges and prioritizes patients in the ED for early intervention to prevent unnecessary admissions and expedite appropriate discharges out of the emergency room. It also acknowledges the growing number of hospitalized outpatients, including surgical patients and those under observation. Case management in the Adaptive Model begins before the patient enters the hospital, with pre-operative assessments, education and planning.
Additionally, the Adaptive Model recognizes the increasing social complexity of patients. This has evolved from a singular social work function, to care teams equipped to handle these complexities through comprehensive, multidisciplinary approaches that adapt to the local community.
The traditional triad model of hospital case management is no longer sufficient in today’s fast-paced healthcare environment. The Adaptive Model provides flexibility to the local landscape and the transformative nature of healthcare. The model encompasses disciplines outside nurses and social workers as integral to the case management team such as non-licensed professionals, physician advisors and pre or post hospital case management roles. The Adaptive Model requires a new workforce with strong communication skills and technology acumen who can leverage the fast-paced technological advancements currently on the horizon in the case management space. Finally, the model expands the focus outside inpatients to encompass independent staffing structures for emergencies, pre-surgical, bedded outpatients and post-discharge outpatient settings. The Adaptive Model leans into the change for utilization review from one part of the three-legged stool to its own specialized set of professionals deeply tied to the clinical revenue cycle team members, thus shifting some of the requirements back to the case management team members. As healthcare continues to evolve, the Adaptive Model offers a pathway to a more efficient, patient-centered case management approach.