Some healthcare organizations are finding that embedding case managers in primary care provider practices is an ideal way to help high-risk patients receive the care coordination and engagement they need to remain healthy.

  • Case managers help identify services patients need to overcome barriers.
  • When patients and primary care staff have questions, embedded CMs are there to provide “curbside” help.
  • Case managers can facilitate warm handoffs.

Case managers (CMs) embedded in primary care provider practices are at the right place and right time to help patients most in need of care coordination and engagement. These high-risk patients need help before they return to the hospital or are in crisis.

Healthcare providers now have financial, as well as quality, incentives to help their highest-utilization patients improve their health because the government under the Affordable Care Act (ACA) is holding providers accountable for healthcare costs, says Sreekanth Chaguturu, MD, vice president for population health management at Partners HealthCare in Boston.

“Over the last couple of years, we’ve seen a growth in healthcare expenditures, and the government passed new regulations that hold us accountable for healthcare cost growth,” Chaguturu says.

Partners HealthCare has succeeded in reducing healthcare costs in 2006 MGH demonstration projects targeting Medicare patients with community-based practices. These projects led to a commitment to population health management and the expansion of case management services to other primary care settings within the Partners HealthCare community, says Jennifer Wright, RN, CCM, manager for the Integrated Care Management Program (iCMP) at Newton-Wellesley Physician Hospital Organization in Newton, MA.

Wright describes the following examples of how case management embedded in primary care helps high-risk patients:

Case managers identify services primary care patients need to overcome barriers. CMs help patients identify social agencies and community services that are appropriate and might help them maintain optimal health. “We identify elder service agencies and programs and work aggressively with trying to help elderly patients [when appropriate] with referrals to hospice or palliative care in the community,” Wright says.

Case managers help patients achieve their own goals and desires when faced with major healthcare decisions, she adds.

“For example, one case manager had an 89-year-old patient who had been in and out of the hospital with shortness of breath from congestive heart failure,” she says. “His daughter brought him to the emergency department, and he refused to be hospitalized.”

So the iCMP case manager, embedded in the primary care practice, worked with a home care agency and infusion company to help the patient receive his diuretic at home. These intensive home services allowed him to breathe more comfortably and to stay home, honoring his preference.

“We also arranged with the patient and his daughter, connecting them with hospice in the event the treatment didn’t work,” Wright recalls.

The man was able to live at home for six months before being placed in hospice care, she adds.

“We needed outside-of-the-box thinking because as healthcare changes and evolves so quickly with all of its moving pieces, it’s hard for folks to manage,” Wright explains.

The CM team also includes social workers who work with nurses and others to assist patients with psychosocial health issues, including substance use, food stamps, transportation, at-home needs, and getting to doctors’ appointments.

Case managers field curbside questions. As CMs enroll patients and see patients with whom they have established a relationship, they become a resource for primary care staff and patients, Wright says.

“They field curbside questions,” she says. “Even though they have a defined group of patients, they become a resource for the practice for other challenging situations/patients; we’re education ambassadors.”

For instance, primary care providers often ask CMs questions, such as the following:

  • How do I connect this patient to hospice care?
  • What kind of services are available in this area for this patient?

The curbside consult helps patients, but also improves relationships with primary care staff, Wright notes.

It’s understood that the curbside consults are limited and intended to help PCP staff learn more about available community resources so they could eventually handle these patient questions on their own, she says. “The social worker might say, ‘I can do a limited engagement with this patient, but I can’t manage them long-term,’” she adds. “We want to be helpful to our PCPs and the big universe of patients, but we have to be mindful about how we set that expectation as our core population includes those in our risk contracts.”

The goal is for patients to work with staff at the practice, and having the staff seek consulting or coaching help from case managers as necessary, she explains.

Case managers facilitate warm handoffs. “They do home visits from time to time,” Wright says. “We have elders who have mental health issues or social isolation, and when we’re introducing them to a different agency, our social worker or CM will go to their house to be a warm handoff to the new service.”

Also, when patients are seen at the emergency department, case managers are notified and when it’s feasible, they will head to the ED to meet with the patient, she adds.

CMs market primary care services to patients. There is a two-page integrated care management brochure that patients can pick up at their providers’ offices. It includes photos of the care management team and explains a little about what they do.

For example, the brochure, sponsored by Partners’ Integrated Care Management Program, says, “Patients are matched with a nurse care manager who works closely with them and their loved ones to develop a customized healthcare plan to address their specific healthcare needs…”

CM services are listed, including these examples:

  • care coordination led by a nurse care manager,
  • access to specialized resources such as mental health, pharmacy, and community resources expertise, and
  • direct patient involvement through health coaching and shared decision-making.

The brochure also has testimonials with photos and several frequently asked questions.