JUNE 28 - JULY 2, 2020  
30 years of Care Transitions Across the Full Continuum

PP302 – One Plus One is Greater Than Two: Integrating to a Combined Nurse and Social Work Care Management Model

PP302 – One Plus One is Greater Than Two: Integrating to a Combined Nurse and Social Work Care Management Model

Restructuring a new identity for Care Management by merging two formerly distinct departments requires appreciation for the past while encouraging employees to share in becoming stakeholders in patient care-coordination, ensuring quality care transitions to the next level of care.

Transdisciplinary team approach allows multiple disciplines to utilize the best of their practices with the shared goal of improved delivery of care to patients.  Cultural transformation, trust, and change theory utilization are all necessary components for the integration of two formerly separate disciplines into one team to be successful.

Changing the Care Delivery Model implements best practices to improve patient care and caregiver satisfaction.  Leading through change and continuous input from team caregivers are critical to the successful integration of two disciplines into one cohesive team.

Guiding principles, mission, values must be defined for the nursing department.  A shared governance approach to creating a roadmap of the journey, with milestones that need to be reached will enable the team to visualize the process.  Standardizing the process for Care Management enhances equality of disciplines, patient safety, engagement in department metrics and goals, and professional collaboration.   Standardizing the approach to transition into the new care delivery model along with the approach to orienting new department employees will be critical to team building (Dus, 2018).

Outcomes include improved patient satisfaction scores, improved completion of patient assessments within 24 hours of arrival, and improved Summary of Care completion rate.

Conclusions: The outcomes correlate to successful implementation of best practices to improve quality of patient care and caregiver satisfaction.  .


Dus, J. E. (2018). Creating a new nursing identity during a merger: Respecting the past and designing the future. Nurse Leader, 17(2), 121-124.  20190412160426396311402