Executive Summary

Health care organizations increasingly are incentivized to focus on preventive care. Case managers can extend their reach by collaborating with community partners to provide non-medical services to elderly patients.

• Patients often need help with transportation, light housekeeping, even housing.

• Sometimes, patients are lonely and just need someone to look in on them or to call on the telephone.

• Faith registered nurses provide in-home visits for education and faith support.


As the Affordable Care Act nudges health care organizations toward preventive care and efficient, holistic solutions, some case managers are finding that they can do more for their patients if they seek help from all available community resources.

The idea is for case managers to refer patients to community-based organizations (CBOs) that provide elder services or other types of help — typically for free or at an affordable cost.

For example, an elderly patient who has scheduled orthopedic surgery might need help with transportation and grocery shopping when she returns home. A case manager could help the patient schedule physical therapy and follow-up medical care, but if the patient is unable to get to the appointments, her recovery could be threatened, says Karen R. Vanaskie, DNP, RN, MSN, care management program director at Scottsdale Health Partners in Scottsdale, AZ.

“The patient might need help with light housekeeping and with making meals,” Vanaskie adds. “We want to make it an easy transition for them, and finding these resources is something we can do before the surgery.”

Community organizations are important partners for case managers when the goal is to look at a population of patients on a continuous basis, notes Anne Meara, RN, MBA, associate vice president of Network Care Management at Montefiore Health System in Bronx, NY. Montefiore has a pioneer accountable care organization (ACO) that focuses on providing quality patient care and focusing on cost drivers. It’s an alternative to the traditional fee-for-service system. (Look for further information about case management and the ACO in the upcoming June 2015 issue of Case Management Advisor.)

“We look for people who have incurred high medical expense, who are being readmitted to the hospital, and who are newly diagnosed with a chronic disease,” Meara says.

Case managers do thorough assessments of patients’ needs and identify issues that are not medical but can affect their health, she explains.

For example, housing is a major issue for this population, she notes.

“We’ve established relationships with every major housing organization in the Bronx,” Meara says.

“Depending on the type of problem, we’ve developed pathways involving housing, and all case managers are expected to handle certain situations,” Meara says. “If we identify this person is living on the street, the accountable care manager now works with an expert in housing — a community-based housing partner — and we might call in legal services.”

Case managers in the emergency department can call one of the housing organizations at any time of the day or week. “If we have someone in the emergency department who is at risk in the area of housing and the physician would otherwise discharge this person, we can have someone come to the ED and take the person to safe housing care,” Meara explains.

Housing can have a big impact on patients’ health, she notes.

“Because of an unstable housing situation, patients cannot address their health care needs: They can’t pick up medications, and their lives are chaotic,” she says. “They come to the emergency department and are very sick.”

Other services where case managers will work with CBOs include transportation, caregiver fatigue, dietary issues, loneliness, and depression, she adds.

Vanaskie researched her area to see what types of services were available for elderly and chronically ill patients. Her investigation turned up a long list of ways CBOs could help, including providing transportation to doctor’s appointments or the grocery store, housekeeping services, home visits by volunteers, meals assistance, faith nursing care, and other services.

“I thought I knew all of the resources in the community because I’ve been doing this for 30 years,” Vanaskie says.

But she found that there were vastly more resources available than she imagined. There were so many that the organization established a weekly community resource meeting in which each week of the year, a different CBO, hospice, or agency meets with case managers to discuss their work. Some of these organizations would charge the patient or the insurance, but many offer free or reduced price services, she says.

“I get calls every week from companies or agencies or community groups that want to talk about the services they give to patients,” Vanaskie says. “We’re booked through June.”

Community meetings have helped extend case management’s reach in even some unexpected ways, she notes.

“A lot of times after the companies meet with us and hear about our population and what they struggle with, they come back with new programs that they put in place because of our population,” she says. “One non-medical in-home services company came back with a little package deal for patients who are just out of the hospital; for $80, they can have an attendant come into their home for the first five days home.”

When an organization has a service that a patient might need, but there is a small charge, case managers are very upfront with the patient about potential costs, Vanaskie says.

“Ultimately, it’s the patient’s decision,” she says.

One nonprofit organization that works with Scottsdale Health Partners is Duet: Partners in Health & Aging, in Phoenix. The largest number of referrals for Duet’s free and volunteer services comes from case managers, says Elizabeth Banta, Duet executive director.

Duet provides services for those who are homebound, including groceries, rides to medical appointments, friendly visiting and phoning, paperwork assistance, handyman services, home safety assessments, respite assistance, and computer assistance, she says.

The organization also has caregiver support groups, workshops, seminars, and services providing nurses in faith communities, she says.

“Many of the individuals that case managers are helping are coping with some kind of challenge related to their health or a health crisis,” Banta says.

“They’re struggling to understand what’s out there in the community and how they can have a high quality of life in their own homes,” she explains. “We partner with organizations that provide hands-on care.”

Duet and organizations like it rely on volunteer work, as well as paid staff. “We inspire people to volunteer, and most volunteers are matched up with one person,” Banta says.

Every community in the United States has an Area Agency on Aging and nonprofit organizations that can help, Banta notes.

“We’re convinced that this type of supportive range of services is helping people stay well longer,” she says. “Particularly, a faith community of nurses who know when people are discharged from the hospital — and can be an advocate for patients — can help reduce readmissions.”

Faith community nurses, who also are called parish nurses, are available to help people — at no charge — in many communities. Some nurses are unpaid professionals and others are employees, but all have a valid license in their state and are registered nurses, says Carol Heimann, MA, RN, faith community nurse with Resurrection Lutheran Church in Scottsdale. Heimann also is on the board of Duet.

“Our faith community nursing was started by a Lutheran chaplain, but there are faith nurses in Hindu and other religions,” Heimann says. “We do not charge for my services, and I don’t limit my practice to people who are members of my church.”

To many elderly patients, faith nurses are part of their social network, their church community, Vanaskie says.

“Even receiving a phone call from a faith nurse gives them a peace of mind that someone is looking in on them,” she explains. “A lot of the elderly are isolated.”

The case manager’s role is to get the various community organizations engaged with patients, Vanaskie adds.

“We like to capture our patient population before they’re at high risk,” she says. “Case management has been known to come in when there’s a crisis; we know we don’t do enough with end-of-life planning.”

Heimann typically works with case managers and social workers, sometimes sitting in on care meetings and interpreting for families what is being said.

“I know these people, which gives me a leg up on case managers who only see them in crisis,” she explains. “Some people I see on a regular basis to keep tabs on them.”

Some faith nurses will run blood pressure clinics at their church, but Heimann’s care is not hands-on nursing. “I do a lot of counseling if someone has a new medical diagnosis. I can answer questions, help them wade through Medicare or whatever their insurance is,” Heimann says. “I can answer medical questions.”

The focus of faith community nursing is the integration of faith and health, she notes.

“I pray with people and have devotions for them, and that’s a big part of my practice.”

Case managers can refer patients to faith nursing programs when there are additional nursing education services they need or when patients mention they would like meet with someone from the faith community but do not have a local church, she says.

“Faith community nurses are very holistic. We look at body, mind, and spirit,” Heimann says.