Apply Evidence-based Case Management/Care Management Models, Processes, and Tools

✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on June 26, 2025.

Case management models

A case management model is a framework for case management practice within an organization. It includes the case manager’s (CM) functions, roles, and responsibilities. The model may also include the relationship between case managers and other professionals and stakeholders. Many factors determine an organization’s model, including the staff’s professional discipline(s), the patient population, and the organization’s size.

Hospital case management models

In the acute care hospital setting, most models focus on the following three responsibilities:

(1) Patient flow – Making sure the patient moves through acute care in a timely manner

(2) Utilization management (UM) – Communicating with payer sources

(3) Discharge planning (DCP) – Moving the patient to the next level of care, including assessing the patient’s needs after leaving acute care, and ensuring safe, timely, and appropriate discharge with the necessary resources

Case management models are differentiated according to who is responsible for each task. Most case management models are a variation of one of the following:

Integrated inpatient case management model – In this model, a single nurse case manager performs all three responsibilities. A social worker may be consulted when appropriate.

Dyad model – Here, registered nurse (RN) and social worker (SW) CMs work together in the case management department. They may co-manage the patient, with the RN handling education and medical issues and the SW focusing on financial, social, and discharge needs. Alternatively, an initial assessment may determine whether the client’s primary needs are medical or social; the appropriate CM would take responsibility for the client, with the other available as a resource.

Triad model / Collaborative case management – This model is like the dyad model, but a third person takes on utilization manager (UM) activities (working with payers), leaving the RN and SW CMs to focus on patient flow, transitions, and DCP.

Each model has strengths and weaknesses. For example, in the integrated case management model, the CM is familiar with the case. She communicates with the patient, payer, vendors, physicians, and other staff. This centralization of responsibilities minimizes duplication and fragmentation of work, which may be more cost- and time-efficient. On the other hand, it is time-consuming for the CM and requires adequate staffing, as each CM will carry a small caseload.

In the collaborative model, time-consuming UM tasks are removed, allowing the CMs to focus on their primary functions. However, this model can lead to redundancy in tasks such as assessments and chart reviews. For this reason and others, collaborative case management requires excellent communication between team members. It operates best when team members work in the same department and report to the same supervisor.

Other case management models

Outside the acute care hospital setting, other models meet the needs of the population served and the case management setting.

Integrated case management – Integrated case management (not to be confused with integrated inpatient case management) was developed to better serve clients with both physical and mental conditions. In this model, a single CM assists the client and his support system on all barriers to health, including those related to mental health and substance use disorders.

Telephonic case management – In telephonic case management, the CM provides case management services virtually via telephone, email, or videoconferencing. Telephonic CM programs may follow a comprehensive model or a team model. In a comprehensive model, a single CM handles all aspects of case management, including utilization review, discharge planning, medical and psychosocial needs, education, and care coordination. In a team model, multiple specialists coordinate care according to their area of expertise. The team may include:

Nurse case manager for medical needs

  • Social worker for psychosocial needs
  • Behavioral health specialist (if needed)
  • Utilization review nurse for authorizations and benefit coordination

Field case management – The field case management model is utilized by insurance companies/payers, workers’ compensation, and community-based organizations, with the CM visiting clients at home or in the community.  For workers’ compensation specifically, a single CM communicates with the worker, the employer, and the physician. The CM attends medical appointments with the injured worker and may visit the client’s home and work site. The CM is responsible for medical case management, return-to-work coordination, and job site analysis.

The case management process

According to the Commission for Case Manager Certification (CCMC), the case management process consists of the following phases:

  • Screening
  • Assessing
  • Stratifying risk
  • Planning
  • Implementing
  • Follow-up/Monitoring
  • Transitioning
  • Post-transitioning communication
  • Evaluating outcomes

The phases are generally sequential, but many phases take place concurrently, or they’re revisited and repeated as needed. For example, a patient may present a new problem during follow-up. In this case, the CM moves to the planning phase for that problem while continuing through the phases for the original problem. The process continues until all the client’s needs are met.

This article shares a portion of the information covered on this topic in CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025). For more details on the case management process and related concepts, purchase your copy at CCMCertificationMadeEasy.com.