Integrated Case Management in the Acute Hospital Setting

Integrated Case Management (ICM) ensures patients and families receive excellent coordinated care across our health system. ICM is not limited to acute care. Integrated care touches all aspects of a patient’s care journey across the care continuum – acute, ambulatory care centers, provider offices, home, and pre- and post-acute facilities. ICM ensures continuity of care and reduces fragmentation of care. As healthcare systems continue to move into value-based care models, in order be successful, this will require comprehensive evidence-based coordinated care to improve utilization, quality, and patient outcomes.

Success of ICM depends on human relationships (patient, families, clinicians) and information flow (data sharing, documentation, communication). Seamless standard processes need to focus on both relational and informational workflows. ICM brings together patients, families, clinical caregivers, care team members, payers, other sites of care, and community resources under standardized processes to achieve shared goals.

By leveraging the collective expertise of providers, clinicians, nurses, social workers, pharmacists, community health workers, the team ensures holistic people-centered coordinated care. The ICM model brings together people, processes, and technology under one integrated care coordination team aligning interprofessional expertise to support patients and families in self-managing their health. By focusing on the individual goals and what matters most to each patient, integrated care reduces fragmentation, enhances communication, and drives better outcomes.

Structured Interprofessional Rounds (IPR) during patient hospitalization are integral team meetings that bring together diverse hospital healthcare professionals to collaboratively develop a unified plan of care. By including patients and families, IPR enhances safety, reduces delays, and shortens hospitalization. This structured approach fosters clear communication, aligns clinical expertise, and shifts care from siloed practices to a coordinated, team-based model grounded in collective knowledge.

Patients often moved across multiple providers, care settings, and services through their healthcare journey. Each transition introduces potential risks, making timely and accurate information exchange essential for patient safety and continuity of care. To mitigate these risks, a standardized process for warm handover communication is critical. This approach ensures that key clinical details, patient preferences, and care goals need to be clearly documented and conveyed between teams, fostering collaboration and reducing fragmentation.

By embedding warm handovers into culture where patients are never truly “discharged,” healthcare organizations can drive accountability, improve outcomes, and deliver seamless, high-quality transitional care. The Joint Commission Center for Transforming Healthcare (2014) defines it as “the transfer and acceptance of patient care responsibility achieved through effective communication” underscoring that it is not merely an exchange of information but a formal transition of accountability. When handovers are ineffective, the consequences can be significant and far-reaching including delays in treatment, inappropriate or omitted interventions, adverse events, and increase hospital length of stay. These failures often lead to avoidable readmissions, higher healthcare costs, inefficiencies caused by rework, and most concerning, minor, or major patient harm. Such risks highlight the need for standardized communication tools and structure processes to ensure clarity, continuity, and patient safety during every transition of care.

Key evidence-based standardized components of communication include identifying the situation, background, assessment, and background (SBAR). Questions to consider and descriptions can be found in the table below.

Reference: Adapted from AHRQ TeamSTEPPS 2.0

In summary, Integrated Case Management is not just a best practice—it is a strategic imperative for healthcare organizations committed to excellence. In an era where patients navigate complex care landscapes, ICM offers a proven framework to eliminate silos, strengthen communication, and deliver truly person-centered care. Structured approaches like Interprofessional Rounds and standardized warm handovers are more than operational tools; they are catalysts for safety, efficiency, and trust. When we embed these principles into our culture, we transform transitions into opportunities for better outcomes, lower costs, and enhanced patient experiences. The future of healthcare demands collaboration, accountability, and innovation—ICM delivers all three.

References:

Agency for Healthcare Research and Quality (AHRQ). Team Stepps 2.0. Retrieved from:

https://www.ahrq.gov/teamstepps/index.html

National Transitions of Care Coalition (NTOCC) (2022). Care Transition Bundle Seven Essential Intervention Categories. Retrieved from: Revised Care Transitions Bundle 3.28.2022.docx

Newman, M. B. (2022). Achieving success in value-based care: Integrating case management and technology base practices. CMSA Today. Retrieved from: Achieving Success in Value-Based Care: Integrating Case Management and Technology Best Practices – Case Management Society of America

Vundi, N., Clouser, J. M., Adu, A. K., Li. J. (2023). Implementation and function of interdisciplinary rounds: An observational multisite hospital study from project ACHIEVE. Journal of Hospital Medicine. Https://doi.org/10.1002/jhm.13062

Lisa Simmons-Fields, DNP, MSA, RN, CCM, CPHQ, FCM, serves as the director, System Population Health and Care Management for Trinity Health System, a multi-institutional Catholic healthcare delivery system spanning 25 states. In this role, Lisa collaborates with leadership and teams across clinical, business and community health domains to improve the health and well-being of our patient populations. Lisa is passionate about creating standard evidence-based programs that support high quality patient care delivery systems. Lisa currently serves as president for the CMSA-Detroit Chapter and is a member of the Editorial Board of CMSA nationally. Lisa also serves as co-chair of the Epic Care Management Advisory Board.