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The evolution of a hospital-based decentralized case management model.

The authors present a case study of a highly integrated case management program and the redefinition of the clinical practice model that evolved across the continuum of care as the integration process was achieved. The central leadership role of the clinical care coordinator (an advanced staff nurse role) as the front-line link between the case manager and the staff nurses was seen as one key in the model's success. Success was further enhanced by: development of objective-based versus time-oriented pathways; involvement of home health earlier, especially in the more complex discharge plans; and a refocus of the patient education process. Future initiatives include refocusing the patient education component as part of a "Steps to Recovery" approach that includes appropriate aspects of the objective-based clinical pathways and expanding the number of case management models to include currently underrepresented patient populations.