The bedside case manager role is quickly evolving in acute care facilities across the United States. With this role comes a wide variety of expectations. Acute care facilities are developing their own job descriptions for the bedside case manager role based on each institution’s individual needs (Tahan, 1993). The development of the bedside case manager role has emerged because of the acute care institution’s need to continue to provide quality care in a continuously changing, cost-conscious health care environment. “The nurse case manger role is a form of professional nursing practice designed to enhance quality client care while simultaneously promoting cost-effectiveness” (Lancero & Gerber, 1995). The bedside case manager is generally an experienced professional nurse who not only cares about the quality of care delivered to the patient but has the necessary financial knowledge to provide the finest care at a nominal cost. The focus of practice for the bedside case manager is the patient and the patient’s support person(s), not the patient care team members who are providing the care. The bedside case manager attends to all of the needs and concerns expressed by the patient and the patient’s support person(s). The bedside case manager coordinates resources to meet patient needs (Mahn, 1993). The bedside case manager looks at the patient holistically and brings a broad knowledge base and competent nursing skills to the patient care arena. The bedside case manager role can be divided into the two broad categories of: 1.) Qualifications and 2.) Responsibilities.

          There are many qualifications the bedside case manager must inherently possess in order to orchestrate quality patient care that meets managed care dictates and requirements. The bedside case manager needs proficient clinical, critical thinking, decision-making, and problem-solving skills (Chimner & Easterling, 1993; Galvin & Baudendistal, 1998) and needs to be expert in all steps of the nursing process (Strzelecki & Brobst, 1997). The bedside case manager “…must also be especially skilled at the management roles of planning, organizing, directing, and controlling patient care” (Wise, 1995, p. 423). The bedside case manager needs to have a firm understanding of disease processes, should be able to handle complex patient situations, and must be able to anticipate complications. Because of the responsibility placed on the bedside case manager, (s)he needs to be confident and independent with the ability to make definitive decisions and take responsibility for those decisions (Smith et al, 1994). To best achieve optimum, quality patient care within prescribed timeframes, the bedside case manager needs to possess a competitive drive and a sense of urgency (Smith et al, 1994) and needs to be able to analyze resource use and variances from the managed care plan/critical pathway.

          In order to strengthen collaboration among the health care disciplines and to delegate patient care tasks effectively, the bedside case manager needs to possess exceptional communication, negotiation, conflict resolution, and collaborative skills and must have a confident people-handling ability (Marr & Reid, 1992; Allred et al, 1995). The bedside case manager must be able to coordinate information from various health care disciplines into a comprehensive biopsychosocial health assessment of the patient.

          For group facilitation and to establish credibility as a team leader, the bedside case manager must have a natural team leading ability. The bedside case manager needs to have a sharp awareness of the patient care team’s weaknesses and needs to be able to utilize the patient care team’s strengths in coordinating the delivery of quality patient care. The bedside case manager must also be able to motivate others and needs to be a solid role model (Smith et al, 1994; Barretto & Haskell, 1997). The bedside case manager role demands that the bedside case manager interface on the same level with the physician. For some nurses, this presents a new experience and requires that the bedside case manager be self-confident and be able to respond assuredly to challenge and pressure. The bedside case manager must be able to recognize conflicting health care practitioner orders and take appropriate action to facilitate amendment of those orders.

          To effectively coordinate patient care, the bedside case manager needs to be self-directed, organized, and flexible with a working knowledge of the patient population. The bedside case manager further needs to have excellent management skills (Tahan, 1993). The bedside case manager must be able to adjust quickly to meet changing conditions with practical solutions. Because the bedside case manager role requires a tremendous amount of education planning and actual teaching of the patient, the patient’s support person(s), the patient care team members, other health care disciplines, and physicians, excellent articulation skills and knowledge of adult learning principles are essential. Not only must the bedside case manager be a capable teacher, but must also demonstrate an ability to be an effective learner. The bedside case manager must be able to learn and process detailed information quickly and thoroughly (Smith et al, 1994).

          To be in tune with the socioeconomic changes taking place in health care, the bedside case manager must have initiative and should possess some comprehension of the financial aspects of patient care as well as an understanding of continuous quality improvement (CQI) principles and change theory. To improve the quality of patient care, the bedside case manager needs to be able to recognize the need for change, institute the necessary steps toward change, and readily adapt clinical practice to incorporate change.

          The bedside case manager role carries with it numerous diverse responsibilities. Some of these responsibilities are new but many are familiar with new twists. The bedside case manager has clinical, management, and financial responsibilities to fulfill in order to coordinate patient care through and across the health care system from admission through and beyond discharge (Wells et al, 1996; Strzelecki & Brobst, 1997). The bedside case manager is a clinical expert who is accountable for procuring, facilitating, and coordinating health care services; managing and negotiating clinical and financial resources; and coordinating discharge plans for the patient. Because some of the responsibilities the bedside case manager will be charged with are new ones, learning needs regarding those new responsibilities will have to be met.

          The bedside case manager is responsible for the comprehensive assessment of the patient and for collecting information from the patient and the patient’s support person(s) regarding precipitating health factors that can be associated with the current hospitalization (Tahan, 1993). Along with gathering information with regard to the patient’s formal and informal support systems, coping ability, education needs, and home environment, the bedside case manger should assess the patient’s health care needs and goals, paying particular attention to the patient’s physical, psychological, social, developmental, functional, spiritual, and financial status. The bedside case manager also needs to assess the capabilities of the patient’s support person(s). The bedside case manager must continue to reassess the patient throughout the hospitalization period for any changes in health care needs to ensure that the patient is meeting defined outcomes within a medically necessary length of stay. Included within the bedside case manager’s continual patient reassessment, is a visual assessment of the patient during change of shift report.

          All of the accumulated patient assessment information is used by the bedside case manger to identify actual and potential patient problems; to formulate appropriate nursing diagnoses; to create patient goals together with the patient and the patient’s support person(s); to institute interventions that will facilitate patient goals; and to plan for the patient’s discharge, including links to community resources, or eventual transfer to another level of care. As part of the discharge plan, the bedside case manager needs to help the patient develop a network of health care services. Effective discharge planning and teaching can alleviate repeated hospital re-admissions (Nugent, 1992).

          Furthermore, the patient assessment information is used by the bedside case manger in collaboration with the patient, the patient’s support person(s), the physician(s) and all of the other health care disciplines caring for the patient to establish a case management plan that, along with following a clinical course, includes individualized patient care outcomes that are prioritized. “Mutual setting of goals between the patient and the health care team results in realistic outcomes” (Nugent, 1992). The bedside case manager is responsible for participating in the development of critical pathways and often times is the instigator of new critical pathway formation. The bedside case manager uses “…critical pathways to intervene at key points and assure appropriate durations of stay and to monitor the use of resources” (Smith & Wolf, 1997).

          As the patient care team leader, the bedside case manager participates in direct patient care activities including a visual assessment of the patient during change of shift report and any other patient care activities that only a registered nurse is licensed to perform. To identify the most current patient care needs and to help with the facilitation of self-care activities by the patient, the bedside case manager reviews the patient’s physical and psychosocial assessment daily with the members of the patient care team. The bedside case manager will perform an independent physical and psychosocial assessment when questions arise or when the patient’s status changes. The bedside case manager addresses patient care needs with the physician(s) during rounds. Also during rounds, the bedside case manager requests any pertinent orders from the physician(s) and selects the appropriate clinical pathway soliciting input from the physician(s) and any other health care disciplines involved in the care of the patient. The bedside case manager is also responsible for telephoning the physician(s) when any condition regarding the patient changes or when new orders are needed. In addition, the bedside case manager is responsible for communicating patient progress, including the patient’s actual day of stay as well as the patient’s projected length of stay, to the oncoming staff during change of shift report.

          Part of the hands on care the bedside case manager is responsible for is documentation of variances from the case management plan and documentation of strategies to correct the variances. The case manager, together with the physician(s) and all of the other health care disciplines caring for the patient, needs to continually reassess how the case management plan is meeting the patient’s needs and update the plan as needed. Along with updating the case management plan, the bedside case manager is also responsible for designing and implementing a comprehensive teaching plan for the patient and the patient’s support person(s) which includes, but is not limited to, information about the patient’s illness, hospitalization, anticipated or planned procedures, medications, activity, diet, environment, restrictions, self-help interventions, health care resources, and discharge plans. The bedside case manager also provides a great deal of emotional support to the patient and the patient’s support person(s). The bedside case manager is responsible for helping the patient and the patient’s support person to understand the patient’s disease process in order to make appropriate health care decisions. Correspondingly, the bedside case manager refers the patient and the patient’s support person(s) to the most appropriate hospital and/or community health care resources. The bedside case manager must evaluate patient teaching to ensure that the educational needs of both the patient and patient support person(s) are met prior to discharge. To strengthen the effectiveness of patient education, the bedside case manager needs to encourage all members of the patient care team to uniformly reinforce patient teaching during all times of contact with the patient and/or the patient’s support person(s).

          To evaluate the quality and cost-effectiveness of patient care and the effectiveness of the health care team’s patient care interventions, the bedside case manager is involved in conducting quality improvement audits both concurrently and retrospectively (Tahan, 1993). By comparing the projected patient outcome to any variance or unexpected event on a critical pathway, the bedside case manager can swiftly act to correct any deviation and thereby contain costs (Smith & Wolf, 1997). It is the bedside case manager’s responsibility to monitor patient care activities to insure that ordered health care services meet the patient’s needs and are actually being carried out. Correspondingly, it is the bedside case manager’s responsibility to evaluate the outcomes of the patient care tasks and activities delegated to the members of the patient care team and provide a mechanism for feedback.

          Another significant evaluation responsibility for the bedside case manager deals somewhat with public relations. The bedside case manager is involved in seeking feedback and suggestions from the patient and the patient’s support person(s) in regard to their satisfaction with the patient care rendered by all of the health care disciplines caring for the patient. Striving to improve the delivery of quality patient care, the bedside case manager, in collaboration with all of the health care disciplines, incorporates the feedback received from the patient and the patient’s support person(s) back into the provision of patient care.

          Since the bedside case manager role is placed at the managerial level, the bedside case manager has the authority to promptly institute needed interventions. The bedside case manager acts as an informal leader for the health care disciplines caring for the patient and as a formal team leader for the patient care team. The bedside case manager conferences daily with each of these groups “…to evaluate the patient’s condition and outcomes to treatments and services to prevent complications, initiate changes or modifications in the plan of care as necessitated by the patient condition, or promote self-care activities as soon as patient tolerance is evidenced” (Tahan, 1993).

·     The bedside case manager facilitates the patient’s progress through the established case management plan by:

·     Enlisting resources and mediating as needed to ensure that patient outcomes are reached within or before the stated time frames.

·     Assuring that necessary health care services do not go unperformed.

·     Insuring that there is a united effort amid all of the health care disciplines caring for the patient.

·     Taking appropriate actions when variances from the managed care plan are recognized.

          Frequently the patient will have a number of physicians writing orders for health care services. In this situation, it is the bedside case manager’s responsibility to intervene so that needed health care services do get ordered and to ensure that health care service duplication is prevented (Conger, 1998).

          In addition, the bedside case manager acts as a patient advocate to ensure the patient’s present and long-term health care needs are met. The bedside case manager acts as an advocate for the patient by discussing and planning care with the patient, the patient’s support person(s), and the health care disciplines caring for the patient. The bedside case manager further acts as a patient advocate by negotiating appropriate, cost-effective health care services and essential resources for the patient. To assure the patient has access to needed health care services; to guarantee well-timed, cost-effective patient outcomes and quality care; and to prevent repeated or fragmented health care services, the bedside case manager facilitates open communication among all of the health care disciplines caring for the patient (Tahan, 1993) as well as between the patient care team members. At times, the bedside case manager acts as a spokesperson for the patient.

          The bedside case manager supervises members of the patient care team and appropriately delegates and monitors patient care tasks to ensure that the patient receives appropriate, quality care. When monitoring patient care activities, it is important for the bedside case manager to be aware of regulatory agency requirements. The bedside case manager is a valuable resource person for staff members and is involved in team building and patient care team motivation along with providing inservice education and referring staff members to pertinent employee assistance programs. Furthermore, because the delivery of health care is constantly changing, the bedside case manager must have a good understanding of change theory in order to effectively manage any patient care team resistance to needed change.

          Because of the managed care environment and the need to reduce patient care costs, the bedside case manager must be aware of DRGs (diagnosis related groups) and other third party payer regulations and constraints when planning patient care. The bedside case manager is expected to demonstrate direct accountability for the costs incurred by the delivery of patient care (Conger, 1998). The bedside case manager is also involved in negotiating with third party payers for patient health care needs, including continuing care and home care services.

          The bedside case manager is involved with developing and monitoring the annual financial goals for selected patient populations based on DRG group diagnoses. The bedside case manager also assists in designing and implementing new patient care strategies that enhance the quality of care delivered to the patient while improving the lucrativeness of that same care. Before and after these new patient care strategies are implemented, the bedside case manager helps with researching and evaluating their cost-effectiveness, with regard to appropriate resource utilization. With the goal of overall operational improvement, the bedside case manager, in collaboration with representatives from all hospital departments, identifies and examines both intra and inter departmental enhancement opportunities implementing and later evaluating the optimum plans.

          Because the bedside case manager will be unfamiliar with some of the responsibilities expected in the new role, certain learning needs will have to be met. Most of those learning needs revolve around the bedside case manager’s management and financial responsibilities.

          If not already utilized in the bedside case manager’s practice, one of the management skills that will need to be learned is effective time management. Because the bedside case manager role demands that the bedside case manager juggle numerous problems and people on a daily basis, efficient time management skills are imperative to the success of the case manager’s ability to direct patient care. As part of time management, the bedside case manager must learn to stay focused on the patient, seeing the entire health care picture not just the immediate clinical situation (Conger, 1998). Along this same line, it is important for the bedside case manager to be able to effectively progress the patient from admission to discharge, which can mean advocating for different levels of care within the same hospitalization period. “Development of level of care transitions is crucial to case management practice” (Conger, 1998). The bedside case manager must learn how to make informed patient care decisions and commit to them (McMurry, 1997). Accordingly, because many of those patient care decisions involve input from the other health care disciplines caring for the patient, it is important for the bedside case manager to learn competent collaboration and negotiation skills.

          Other management skills the bedside case manager needs to learn are how to utilize health care resources, the “use of continuous quality improvement concepts, the ability to challenge traditional nursing modalities, and (an) introduction of practice changes based on current research…” (Strzelecki & Brobst, 1997). The bedside case manager also needs to gain management knowledge in regulatory agency standards, “…diagnosis-related groups (DRGs), utilization management, managed care, and the balance between quality and cost containment” (Smith & Wolf, 1997). The bedside case manager’s consideration of managed care principles needs to include both the measurement of quality care and cost-containment methods (Conger, 1998). It will also be necessary for the bedside case manger to learn how the new role demands the following to be carried out: the development of “…clinical pathways (and) standardized protocols,…patient rounds, coordination of care,…and evaluation of patient outcomes” (Conger, 1998). Patient outcomes are often evaluated through tracking variances from the set clinical course in the clinical pathway. The bedside case manager “…must learn to determine the cause of the variance whether it be patient, provider, or system related and then work to find ways to correct the variance” (Conger, 1998).

          Financial skills the bedside case manger will need to learn include “the decision making required for determining the most cost effective way to manage care (and)…the measurement of cost effectiveness of client care. This includes understanding of LOS (length of stay) issues and appropriate use of resources. To do this, the nurse needs to undergo a transformation in thought process” (Conger, 1998, pp. 130, 132). Traditionally, nurses have held that the patient deserves the best care no matter what the cost. With managed health care, part of that belief needs to change. The patient still deserves the best care, but now it has to be delivered within a set budget. In light of this fact, the bedside case manger needs to become familiar with resource utilization, numerous health insurance plans, third party payer reimbursement requirements, prospective payment systems, and how DRGs affect reimbursement and length of stay.

The bedside case manger role is now becoming more prevalent in acute care facilities across the United States. Each facility that incorporates the bedside case manager role for patient care delivery has to develop a role description unique to the needs of the institution it is to serve. This role description will include qualifications and responsibilities required of the bedside case manager. Because some of the responsibilities incorporated into the bedside case manager role are new, education needs relevant to those new role responsibilities will have to be satisfied.

Allred, C., Arford, P., Michel, Y., Dring, R., Carter, V., Veitch, J. (1995). A cost-effectiveness analysis of acute care case management outcomes. Nursing Economics, 13(3), 129-136.

Barretto, P., Haskell, S. (1997). Development of a nurse entrepreneurial role: Patient care manager. Nursing Economics, 15(5), 262-264.

Chimner, N., Easterling, A. (1993). Collaborative practice through nursing case management. Rehabilitation Nursing, 18(4), 226-230.

Conger, M. (1998). Integration of acute care CNS and case manager roles. Critical Care Nursing Clinics of North America, 10(1), 127-134.

Galvin, L, Baudendistel, D. (1998). Case management a team approach. Nursing Management, 29(1), 28-31.

Lancero, A., Gerber, R. (1995). Comparing work satisfaction in two case management models. Nursing Management, 26(11), 45-48.

Mahn, V. (1993). Clinical case management: A service line approach. Nursing Management, 24(9), 48-50.

Marr, J., Reid, B. (1992). Implementing managed care and case management: The neuroscience experience. Journal of Neuroscience Nursing, 24(5), 281-285.

McMurry, E. (1997). Case management: A joint effort where do you start? Orthopaedic Nursing, March/April Supplement, 30-32.

Nugent, K. (1992). The clinical nurse specialist as case manager in a collaborative practice model: Bridging the gap between quality and cost of care. Clinical Nurse Specialist, 6(2), 106-111.

Smith, G., Danforth, D., Owens, P. (1994). Role restructuring: Nurse, case manager, and educator. Nursing Administration Quarterly, 19(1), 21-32.

Smith, G., Wolf, D. (1997). Orientation program for a hospital-based dual case manager and educator role. Journal of Nursing Staff Development, 13(2), 77-82.

Strzelecki, S., Brobst, R. (1997). The development of an acute care case manager orientation. Journal of Nursing Staff Development, 13(5), 266-271.

Tahan, H. (1993). The nurse case manager in acute care settings job description and function. JONA, 23(10), 53-61.

Wells, N., Erickson, S., Spinella, J. (1996). Role transition from clinical nurse specialist to clinical nurse specialist/case manager. JONA, 26(11), 23-28.