A team-based care process can facilitate better case management. The case manager’s role is the glue that keeps the team together in an integrated care management model that incorporates mental and physical health issues.

One such integrated care management team approach has helped a health system improve clinical outcomes for patients, lower costs, and lower rates of healthcare utilization, according to a 10-year study.1

“The care manager’s role is so critical and important,” says Brenda Reiss-Brennan, PhD, APRN, mental health integration director at Intermountain Healthcare in Salt Lake City.

“A care manager is the team member who has the most contact with the patient and family,” she adds. “The care manager is incredibly skilled at developing a trustful, engaging relationship with patients and families around all their conditions.”

Reiss-Brennan is an author on the study, which involved Intermountain Healthcare’s program. The study showed a 23% reduced rate of ED visits for patients in the team-based practices. The rate was 18.1 ED visits, vs. 23.5 visits by patients in traditional practices.1

The research also found that many more patients in team-based practices were screened for depression. This resulted in a higher rate of diagnosis for active depression. For patients in team-based practices, the depression rate was 46.1%, vs. 24.1% for patients in traditional practices.1

Adherence to diabetes care protocols also was higher for patients in team-based practices. The rate was 24.6% vs. 19.5%. Nearly six times as many patients in the team-based practices had a documented self-care plan (48.4% vs. 8.7%).1

Intermountain Healthcare has been integrating mental health in its care management for more than 18 years. It’s a standard process for every member of the team, Reiss-Brennan says.

Patients receiving integrated care management have a consistent experience across disciplines.

“The care manager keeps them on the same page, looking at reports, complex issues, and links to services in the community,” she explains.

The following are the roles that assist with integrated care management:

• Nurse care manager. The nurse care managers provide care management based on the integrated team-based care model. It combines mental health integration and medical home.

“We have a lot of support around them,” Reiss-Brennan says. “Physicians know when to refer to the care manager and meet them regularly as a team.”

The nurse care manager develops holistic care plans, educates patients, and talks with patients about mental health issues, as needed.

“They’re kind of the care management leader and champion,” she says.

• Health advocate. In a primary care provider clinic, a medical assistant who has received additional training assists patients with their medication, Reiss-Brennan says.

“Health advocates look at the patient’s schedule and help with adherence,” she says. “They do follow-up and make sure physicians and care managers have what they need to prepare for a visit with the family.”

Health advocates are certified with medical training. They also undergo additional training in care management functions to support the team, and they’re supervised by physicians and RN-level nurses.

• Care guide. The role of a care guide can be handled by a trained layperson. The care guide helps patients, families, and care teams navigate the healthcare system.

“They are trained in reading the reports — diabetes report, hypertension report, depression report — and they look at gaps and ways patients might need extra help,” Reiss-Brennan says. “They have to be comfortable with looking at reports and finding patterns, but they’re not analysts.”

• Social worker. Bachelor’s-level social workers are the team’s experts in helping to identify patients’ social determinants of health, such as transportation, housing, and other issues.

“They link patients with social services and agencies within the community to help patients, and they bring that information to the entire team, bringing the team together,” Reiss-Brennan says.

“They give the team and primary care providers their assessment and what they think the treatment team should be, and they discuss the assessment with families,” she says. “Here’s the picture and some points and where you should start.”

When patients arrive at their community provider, one team member meets with the patient and family and helps them navigate the first step.

The care management team addresses each patient’s needs and helps find the person a primary care provider home or help from social agencies, as needed, Reiss-Brennan says.


1. Reiss-Brennan B, Brunisholz KD, Dredge C. Association of integrated team-based care with health care quality, utilization, and cost. JAMA. 2016;316(8):826-834.