C O L L A B O R A T I V E C A S E M A N A G E M E N T
Chaplaincy and Care Management – Collaborating to Meet Patient and Family Needs
By Beth Heinz, MSW, LICSW; Alissa Madden, LICSW; and Rob A. Ruff, M.Div., BCC
While most acute care hospitals feature Chaplaincy departments, the roles, responsibilities, and structures of this service vary widely.
The skills and services offered by hospital chaplains are not always clearly understood by other members of the patient care team, including
medical staff members and case managers. But when chaplains and the services they provide are properly understood and effectively utilized,
there is the potential for a collaborative partnership with Case Management that can produce positive effects on the quality and efficient
progression of patient care.
Regions Hospital is a 427 licensed-bed facility in Saint Paul, MN that
has developed such a collaborative partnership. At Regions, Chaplaincy
and Care Management are independent departments, each with its
own director, which are united under a single reporting structure. The
directors of both services report to a single administrator who is also
responsible for Palliative and Complementary Care, Measurements
and Data, and Performance Improvement.
Care Management at Regions Hospital includes (Nurse) Case
Managers and Social Workers. At least one Case Manager and
one Social Worker are assigned to each unit, and collaborate to
provide service for that unit. Case Managers review all cases, and
are responsible for identifying and managing all clinical and payer-
related discharge needs and potential barriers to the progression
of the patient’s care. Social Workers receive cases by referrals that
are generated through various indicators on a patient’s initial
nursing assessment and communicated to Social Work through
the Electronic Medical Record (EMR). As medical staff becomes
aware of issues requiring Social Work management, they may also
refer the case. Referrals are also generated less formally during
interdisciplinary patient rounds. Social Workers are responsible for
identifying and managing any social barriers (and potential barriers)
to the progression of a patient’s care, psychosocial counseling and
interventions with patients and families, and planning for all social
or legal discharge issues. The priorities of the Care Management
team are progression of care and discharge planning. The function
of Utilization Management is performed by a separate department,
which also manages level of care and denials.
The function of the Chaplaincy Department is to provide pastoral
and spiritual care for patients, families and staff. Chaplains provide
support and spiritual counsel to patients and families facing difficult
situations and decisions and those experiencing crisis and emotional
distress. This support and counsel can be more in-depth than the
counseling provided by social workers, and often focuses on different
themes and issues. Chaplains bring a different perspective and
expertise from that of a social worker. They are equipped to deal with
issues that are spiritual and theological in nature – such as helping
patients and families find meaning amid their difficult experiences;
counseling terminal patients and their families regarding death
and dying in order to help them find peace, and addressing ethical
questions of right and wrong, which often incorporate a religious
viewpoint and involve questions of sin and guilt.
Similar to the methods by which cases are referred to Social Work,
there are multiple ways that chaplains can become involved in a case.
Chaplains are unit-assigned, responsible for three or four units each,
and are responsible for assessing and prioritizing patients on these
units who might benefit from chaplaincy involvement. Two indicators
3
are also included on the initial nursing assessment to identify patients
suffering grief or loss or whom the nurse feels could benefit from
spiritual care. These indicators can trigger a Chaplaincy referral,
which is communicated through the EMR. Chaplains participate in
Care Planning Rounds that are held daily on each medical unit. Case
Managers, medical staff and Social Workers can bring chaplains into
a case through verbal communication during these patient rounds.
Chaplains can also become involved by patient or family request.
SPIRITUAL ASSESSMENT
Conducting a Spiritual Assessment (also known as a Spiritual
Inventory or a Spiritual History) is the process of talking with
and listening to a patient in order to get a sense of the shape and
geography of their particular spirituality. Spiritual Assessment
includes learning about the patient’s religious affiliation (if
any), as well as any beliefs and spiritual practices that are
important to the patient. It also includes learning where the
patient finds meaning, purpose, and hope. The goal of the
Spiritual Assessment is to identify the patient’s needs, concerns,
hopes, and resources and to determine appropriate actions
necessary to address those issues.2 While central to the practice
of healthcare chaplains, spiritual assessment is also practiced
by some nurses (witness the nursing diagnosis of “spiritual
distress”), physicians3,4 and other providers.
In addition, a chaplain sees all patients recommended for Palliative
Care, performing at minimum an assessment of the patient’s and
family’s spiritual needs. Chaplaincy staff is also part of the trauma
paging system and are called to all difficult trauma cases and deaths
in the Emergency Department (ED). In these cases, chaplains are the
primary crisis worker, and Social Workers become involved in each
case after admission to a medical unit. Depending on the patient and
family needs, the chaplain may hand the case off to the Social Worker
and Case Manager at that time, or may continue to work the case in
collaboration. Chaplains spend 50 to 75 percent of their time on the
medical units meeting with patients and families. This consistent
availability allows frequent interaction between Care Management and
Chaplaincy staff, and collegial relationships develop as a result.
CHAPLAINCY TRAINING, SKILLS, AND RESPONSIBILITIES
Professional hospital chaplains are theologically educated clergy
who have additional clinical training, experience, and expertise. While
chaplains have at times been misperceived by some hospital staff as a
religious resource pertinent only to actively religious patients, in fact,
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 C O L L A B O R A T I V E
Chaplaincy and Care Management – Collaborating to Meet Patient and Family Needs (continued from page 3)
12 SIGNS
OR SITUATIONS
THAT CAN
TRIGGER A
CHAPLAINCY
REFERRAL:
1 When there has
been a significant
change for the worse in a
patient’s condition.
2 When the patient or family
has received bad news.
3 When the patient or family
is having a difficult time
coping with illness or
hospitalization –
manifested by feelings of
discouragement, loneliness,
hopelessness, lack of
meaning, etc.
4 When a care conference
has been called to discuss
end of life issues.
5 When a patient needs
end-of-life care.
6 When a patient/family
is experiencing
spiritual distress.
7 When a patient/family
utilizes spirituality and
faith for coping and
would benefit from
chaplaincy support.
8 When a patient/family is
wanting and/or needing
someone to listen to them.
9 When a patient/family
requests spiritual support.
10 For spiritual support
prior to surgery.
11 During a long, extended
hospitalization.
12 When a patient/family
are experiencing grief and
loss issues.
C A S E M A N A G E M E N T
chaplains offer spiritual care to all who are in
need. Chaplains strive to help hospital patients,
family members and staff draw upon their
spiritual resources to help them cope more
effectively with and make meaning of their
experience. The practice of hospital chaplains
is analogous to that of hospitalists in that their
work is hospital-based and focused primarily
on responding to the particular needs and
concerns of inpatients and their loved ones.
Chaplaincy support is especially valuable when
patients and families are experiencing crisis,
grief, and loss in units such as Intensive Care
(ICU), Trauma, Burn and Palliative Care.
Some patients who belong to a religious
community or church may receive spiritual
care, counsel, and healing rites from their own
religious leader. The chaplain’s role in such
cases does not displace local religious leaders
but addresses the unique spiritual needs
and concerns that arise in intense medical
environments. In cases where community
clergy are involved, chaplains at Regions
Hospital work to involve and collaborate with
these ministers. The Chaplaincy Department
maintains a wide range of community religious
resources to address specific religious needs
or requests. For example, the Chaplaincy
department at Regions works with a community
religious group that provides support for
Muslim families and patients. Offering this
resource communicates to Muslim patients and
families that the hospital respects and supports
their unique religious beliefs and needs.
Educational requirements for professional
chaplains include a Bachelor’s degree, a
Master’s level seminary degree, and at least
one year of clinical pastoral education. Clinical
training involves chaplaincy practice in a
healthcare setting with supervision. Chaplaincy
board certification generally requires an
additional year of professional experience and
includes written demonstration of defined
professional competencies and a peer review.
The Chaplaincy department at Regions
Hospital seeks to ensure that they are meeting
with the patients who need their services, and
that they are providing quality emotional and
spiritual support to these patients. Individual
chaplains, then, are primarily evaluated in the
following two areas:
• Effectiveness in “case finding” – assessing and
becoming involved in those cases with the
greatest need for Chaplaincy intervention. The
4
Chaplaincy department tracks the number of
patient visits/interventions for each individual
chaplain. However, this metric alone is not
an adequate performance evaluation; it must
be considered in relation to the depth of
support needed and provided for each case.
“Depth” in this context primarily refers to the
chaplain’s ability to journey with the patient or
family through their struggles, processing with
them the questions or concerns that may be
causing them spiritual distress. This requires
skill, learned through experience and training,
to assess through conversation the patient’s
need and willingness to share. Successful
counseling also demands the willingness
on the part of the caregiver to delve with
the patient or family member below surface
level conversation into deeper, more difficult
and painful issues – which might also be
uncomfortable or painful for the caregiver to
discuss. The depth of interventions is difficult
to quantify, but a high number of short-
duration patient visits could be an indicator
of minimal intervention quality. The eventual
patient and family outcomes also provide an
indicator for the effectiveness of the chaplain’s
interventions – did grieving individuals find
a greater level of comfort, or was a family
wrestling with a difficult medical decision able
to sort through the issues and reach
a decision?
• Effectiveness of interventions –
This effectiveness is evaluated against the
professional standards and competencies
for professional Chaplaincy certification.
At Regions Hospital, two of the primary
evaluations are effectiveness triaging and
managing situations of trauma and crisis,
and effectiveness providing pastoral care
to persons experiencing loss and grief. This
includes providing effective pastoral support
for patients, families, and staff respecting
diversity and differences including culture,
spiritual and religious practices, etc. Feedback
from the other clinical staff members
involved in a case is a primary means for
measuring intervention effectiveness. These
caregivers are often able to observe a patient
or family’s emotional situation and the effect
of chaplaincy involvement.
While chaplaincy has no direct accountability
in the reporting structure at Regions Hospital
for Length of Stay (LOS) or Avoidable Days/
Delays, they are part of the team, along
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 C O L L A B O R A T I V E
Chaplaincy and Care Management – Collaborating to Meet Patient and Family Needs (continued from page 4)
with Care Management that collaborates on strategies to improve
LOS for identified areas. For the areas of primary Chaplaincy focus,
including intensive care, trauma, and palliative care, Regions Hospital
benchmarks performance against similar service units at comparable
organizations, and has demonstrated satisfactory performance.
BUILDING COLLABORATIVE PARTNERSHIPS
Regions Hospital is a Level One Trauma Center that has Medical,
Cardiac, and Surgical ICUs, a burn unit, and a step-down trauma unit.
Additionally, a Palliative Care program was recently created which
serves 40 to 45 patients per month. The Chaplaincy Department
prioritizes cases on these units because they commonly involve rapid
changes in patients’ conditions and difficult medical decisions for
patients and families who are often experiencing shock, grief and loss.
In cases on these units, chaplains work with Case Managers and Social
Workers to provide more comprehensive care for patients and families
– addressing the acute emotional and spiritual distress that often
accompanies the difficult medical issues in these cases.
Quite often in these units, progressing the plan of care involves
clinical decisions and choices faced by the patient and family. In such
cases a tension can develop among the following elements, delaying
the efficiency of care delivery and the progression of care:
• The patient’s and/or family’s emotional distress, shock, and grief;
• The need of the attending physician and medical staff to ensure
the patient and/or family accurately understand the diagnosis, the
medical decisions that must be made, and the possible outcomes
and risks for the various clinical options;
• The organization’s need for efficient progression of the plan care,
avoiding medically unnecessary delays to patient care.
At Regions Hospital, Chaplaincy and Care Management find that a
collaborative team effort is very effective when working with patients
and families experiencing these difficult tensions. Medical Social
Workers and/or Case Managers are often able to provide emotional
CHAPLAINCY AND CARE MANAGEMENT CASE STUDY
Mr. P was a 68-year-old patient with a history of heart disease
admitted for surgery to repair a leaking aortic aneurysm. Mr. P’s post-
surgical recovery was difficult and inconsistent. While he alternated
between growing stronger and then weaker, he continued to be vent-
dependent and in need of the level of care provided in the ICU. Mr. P’s
wife and adult son were involved in decision-making about his care.
Mr. P’s social worker considered a palliative care referral, but felt that
the family was not prepared to accept this course and, because of Mr.
P’s periodic temporary improvements and his mental coherence, the
clinical indications for this change of treatment were not definite.
During this period of medical uncertainty, the social worker asked
one of the chaplains to attend a family conference in the context of an
initial palliative care consultation. Although no initial palliative care
referral had been made at this point, the social worker involved wanted
to bring the expertise of the palliative care team to the case, thinking
that this may help move the case forward and would also help palliative
care be prepared if the case was referred. The chaplain joined the social
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C A S E M A N A G E M E N T
support for patients and families, but it can be difficult for a Social
Worker, who is attempting to progress the plan of care and arrange
discharge components, to provide in-depth – and therefore time-
consuming – support to patients and families in crisis or experiencing
grief. Chaplains are allies to help meet patient and family needs by
providing emotional support and pastoral care.
This partnership becomes most visible at family conferences
involving Care Management/Social Work, the attending physician,
and a chaplain. Some patients and families feel comfortable speaking
openly with a chaplain, especially in the areas of trauma, death and grief.
Chaplains can be seen as “safe” – perceived as neutral, empathetic, and
a patient/family advocate. Having both services at family conferences
allows Care Management to more fully care for the non-medical needs
of the patient and family – and to also more fully identify and manage
any barriers or potential barriers to care progression and patient
discharge. The consistent interaction and frequent communication
between the two services on the units and in Care Planning Rounds
facilitates this collaborative partnership, providing a forum for dialogue
focusing on assessing the needs of the patient and family and on
who is best able to meet these needs. Any relevant information that is
gathered by either party is quickly shared with the rest of the team.
In the medical setting with the constant pressure to progress the
patient’s care efficiently, it can be difficult to take into consideration that
many of the decisions that distraught families and patients are asked to
make quickly are human decisions as well as medical decisions. It can
be even more difficult to adequately care for these non-medical needs.
Chaplains, Social Workers and Case Managers in partnership can provide
the necessary support for families to make difficult decisions without
unnecessary delay. The availability of both provides the ability to perform
more extensive counseling as needed. The collaborative partnership of
these two services leads to quality care for patients and families by more
fully meeting their emotional and spiritual needs and also works to avoid
delays related to patient and family coping with difficult situations.
worker, the patient’s family, the attending physician and nurse in the
patient’s room. A trachea tube compromised Mr. P’s communication,
but upon the chaplain’s introduction with the care team, Mr. P indicated
that he wanted to speak with him after the family conference. The
chaplain stayed to meet with Mr. P individually as the others left the
room, and Mr. P expressed, through a combination of words, gestures
and writing, his desire to stop the present course of treatments, that he
did not feel strong enough to continue a curative course of care.
Mr. P had not previously expressed this desire to any of his other
caregivers. The chaplain counseled Mr. P, assuring him that he heard his
choice, and understood and respected his motivations. The decision to
stop curative treatment was difficult for this patient to express. He likely
had a sense that his family might object to his decision, and perhaps
feared that it would be difficult for his caregivers to understand as well.
It was clear that his decision created significant uncertainties. Did his
life have meaning if he could not live long enough to get better? More
importantly, what was the meaning of his choice to stop fighting? In this
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Chaplaincy and Care Management – Collaborating to Meet Patient and Family Needs
difficult situation the chaplain counseled this patient by listening to
and supporting him through the expression of his difficult and painful
choice – supporting him as he struggled to find meaning in his present
situation and the choice he felt compelled to make.
Both Mr. P’s wife and son were surprised by his wish, and had a
difficult time dealing with the decision of whether to support this
change in treatment. Difficult questions arose as they struggled with
the implications of his wish. The son, who is paraplegic from injuries
sustained in a motor vehicle accident several years before, also struggled
with guilt. He felt that Mr. P had supported him during his own medical
crisis years earlier, encouraging him not to give up, and he did not want
to do any less for his father. The chaplain met with the wife and son
over the next two days, counseling them regarding the difficult issues
they were facing. He continued to hold up Mr. P’s expressed wishes, and
explored the implications of those wishes with the family – that Mr. P
was not choosing death, but was choosing to stop treatments because he
felt unable to go any further. Although his spirit was willing to continue,
he felt too tired and weak physically. The chaplain counseled Mr. P’s
family, and his son especially, who struggled to find meaning in the
crisis. To allow for spiritual healing, it was important for the son to find
Beth Heinz
Heinz, MSW, LICSW, is the Senior Director Regions Hospital in
St. Paul, MN, responsible for Best Care/Best Experience, Care
Management, Quality, Data and Measurement, Utilization Management,
Palliative Care, and Complimentary Care. She earned her BA from the
University of Minnesota, an MSW from the University of Michigan, and is
currently an MHA candidate at the University of Minnesota.
Alissa Madden
Madden, LICSW, is Manager of the Care Management Department
at Regions Hospital. She earned her BA in Social Work and Psychology
from the University of Iowa, and an Artium Magister in Social Service
Administration from the University of Chicago in Chicago, IL.
Core Measures – Case Management Drives Compliance, Performance Improvement and Revenue (continued from page 9)
• AMI – ACE Inhibitor (ACE-I) Use For Left Ventricular Systolic Dysfunction
– Threshold: 92% – Reimbursement Weight: 13%
HQID Measures reports for these indicators provided a baseline of past
performance. Blue Cross agreed to the hospital setting thresholds greater
than 90 percent. For any thresholds below 90 percent, however, they
required that the threshold represent a statistical change compared to
past performance. For example, the hospital’s past performance for the
administration of antibiotics to PN patients within four hours of arrival
had been 77 percent. Blue Cross, therefore, required the threshold to be
set at 83 percent to represent a statistically significant improvement.
In 2006, Arnot Ogden was able to meet all of the negotiated
thresholds, and received an additional four percent of their Blue Cross
reimbursements. The contract was then renegotiated for 2007, revising
the thresholds and some of the clinical indicators to the following:
• CHF – Discharge Instructions Provided
– Threshold: 91% – Reimbursement Weight: 15%
• PN – Initial Antibiotic Received Within 4 Hours of Hospital Arrival
– Threshold: 83% – Reimbursement Weight: 10%
11
his own sense of meaning regarding his father’s decision rather than
having a caregiver or chaplain try to “fix” the situation by telling him how
he should understand it. Mr. P’s son eventually came to realize that he
would feel guiltier asking his father to continue fighting than if he gave
him permission to let go. After two days, the wife and son agreed to allow
Mr. P to be removed from the ventilator and placed on comfort care.
The inclusion of the chaplain in the care team allowed the patient to
express his wish, confident that it would be considered in the spiritual
and moral context necessary. The chaplain’s involvement also provided
the needed care and support for a family in crisis, and allowed the case to
proceed more efficiently. Clinically, Mr. P was at a sticking point, unable to
gain enough strength to move to a lower level of care, but not yet engaged
in palliative care. This situation could have persisted for an extended
period. Additionally, Mr. P’s expressed wishes caused turmoil for his
family, faced with a difficult decision. The chaplain is trained to address
the issues in a way that clinical staff is not, and with a spiritual dimension
this family wanted that a social worker’s role does not formally encompass.
Counseling with the patient and family not only assisted them to find
answers to the difficult questions they were facing, but helped them more
quickly reach the decision to allow the plan of care to progress.
Rob A. Ruff
Ruff, M.Div., BCC, is the Director of Chaplaincy Services at Regions
Hospital, a position he has held since 2004. Previously he served as a staff
chaplain at Hennepin County Medical Center in Minneapolis, MN for
14 years. He earned his BA from Concordia College in Moorhead, MN and
his Masters of Divinity from Luther Seminary in St. Paul, MN.
1
Koenig HG: STUDENT JAMA: Taking a Spiritual History. JAMA 291:2881, 2004
2
Joint Commission: The Source, February 2005, Volume 3, Issue 2: 6-7
3
Anandarajah G., Hight E.: Spirituality and Medical Practice: Using the HOPE questions as
a practical tool for spiritual assessment. American Family Physician 63(1): 81–88, 2001.
4
Pulchalski, C. and A. Romer. Taking a spiritual history allows clinicians to understand
patients more fully. Journal of Palliative Medicine 2000; 3: 129-37.
• SCIP – Antibiotics Discontinued Within 24 Hours for Hip and
Knee Replacement Patients (A Clinical Focus Area of the CMS/
Premiere Inc. HQID)
– Threshold: 95% – Reimbursement Weight: 25%
From the payer’s perspective, their motivation for offering such a
performance-incentive contract is similar to the motivation that prompted
CMS to develop the Core Measures program. Higher quality of care
provided to their insured population will produce better patient outcomes.
Overall, this will provide better health management of Blue Cross
customers, resulting in fewer payments and a financial benefit to the payer
organization. This modified contract structure creates a way for hospitals to
demonstrate and be rewarded for the quality of care they are providing. The
ultimate goal is for all patients to receive appropriate evidence-based care.
Contributed By: Tina Davis
Davis, RN, MS, is Senior Director, Continuum of
Care at Arnot Ogden Medical Center in Elmira, NY. She earned her RN
from Keuka College in Keuka Park, NY, and her MS from Binghamton
University in Binghamton, NY. She has served in her current position for
eight years, and has over 27 years of healthcare experience.