Case managers in hospitals and community settings often have to go beyond point of care activities to help patients make significant improvements in their health and healthcare costs.

This is particularly true with patient populations experiencing major barriers to maintaining disease control and health improvement, including housing, food access, transportation.

“We have a journey ahead of us to make more investments, long-term, in addressing patients’ barriers to healthier lives,” says Karen Marie Wilding, FHIMSS, CHCIOe, senior director, quality and value-based care, and affiliate compliance officer, population health, at the University of Maryland Medical System in Baltimore.

Under Maryland’s arrangement with the Centers for Medicare & Medicaid Services (CMS), the state’s hospitals are under a global budget program that reduced total costs of care without shifting them to other parts of the healthcare system. (Learn more at:

The health system has been focusing on the hospital-CMS alignment, Wilding says.

“We have a facility that has partnered with community health workers to address needs in the community,” she says.

“It’s an expectation that care has to be going forward in the community, and we’ve tried hard to ingrain it in the culture,” she adds. “We don’t have it all figured out, but we’ve taken steps forward in those areas, and it is part of population health discussions.”

The University of Maryland Medical System has made investments in improving the health of its patient population. For example, one of its hospitals created a food pantry for diabetic patients to access, Wilding says.

“We had patients who would show up in the emergency department at the end of the month because they ran out of food that was healthy for them, and it impacted their blood sugar levels,” she explains. “Their glucose was not controlled, and they had side effects that put them in the ED.”

The hospital’s food pantry provides shelf-stable healthy choices, such as canned fruits and vegetables.

Care managers and social workers have access to community resources that can help patients overcome health barriers.

“We have many patients we support with community resources like Meals on Wheels, financing housing, and other resources to help them overcome barriers,” Wilding says. “Sometimes, we leverage our pharmacist to help patients align their insurance benefits and copays and costs for specific pharmaceutical regimens.”

For example, pharmacists consult with prescribers about a patient’s medication regimen and suggest suitable drugs that are more affordable, she adds.

A top case management priority is to teach patients to self-manage their chronic conditions.

“For those with chronic disease, it’s about self-management and health literacy,” Wilding says. “Sometimes, we have to address patient’s other issues before we can teach them how to be more involved in their disease decision-making and owning their disease management.”

Case managers can immediately connect patients with services.

“While they’re still in the acute care facility, we have care rounds occurring where they are literally identifying patients and engaging them in facilities that offer wrap-around services,” Wilding explains. “We know that many readmissions are connected to some of these barriers.”

The health system operates a Transitional Care Center, where patients can be seen if the community provider is unavailable in the first few days after discharge.

“The Transitional Care Center has space within a hospital facility,” Wilding says. “The smaller clinics have staff that work both in the clinic and in the hospital, while the larger clinics have a full-time staff nurse, social worker, pharmacist, and a mid-level practitioner and/or a physician.”

After some trial and error, the health system realized that the most effective clinics had at least a nurse, pharmacist, and physician or advanced practitioner, she adds.

Case managers help patients make appointments before discharge. Following a collaborative care team model, the clinic helps patients address their medical needs and barriers to care, she adds.

“If patients can’t get a ride to the clinic, then we arrange for Uber to pick them up,” Wilding says. “Our focus is to reduce readmissions, but one of the parallel benefits is we can help our community while addressing social determinants of health.”

The health system also has partnered with a technology company to provide patients with digital coaching. “They engage with patients in need of health coaching, and we have targeted patients with diabetes and chronic obstructive pulmonary disease,” Wilding says.

Some providers found it to be challenging to incorporate digital coaching into their workflow.

“It’s challenging for practitioners to change their normal course of care and integrate these new options,” Wilding says. “For some of these providers, it takes time to buy into these innovative programs and also to have confidence in the outcomes they promise.”

Providers know that diabetes educators have had positive results with patients, she notes.

“There is less evidence to support social determinants of health interventions than traditional clinical regimens,” she explains. “Clinicians want to have evidence associated with the intervention that they are prescribing or referring patients to, and they want to know the outcomes.”

When case managers try new methods to improve patient self-management, including addressing patients’ social determinants of health or using new technology, it takes time to build a partnership and trust with providers.

“We work closely with our providers to develop workflow and tools. We try to make it easy for them, and we’ve shared our early successes,” Wilding says. “So, when we’ve had a patient that was able to improve medication adherence because they found medications that were low cost, this helped with showing success and outcomes for provider buy-in.”

Wilding offers these suggestions for building trust with providers:

• Be prepared. “Be prepared and thoughtful,” Wilding says. “Make sure providers understand which patients you are targeting, and what you will be able to accomplish.”

For example, one patient visited the ED frequently. Case managers contacted the pharmacist to address the patient’s copays, medication access, and memory strategies to help the patient fill prescriptions and take medication as prescribed, she says.

Soon, the patient’s provider could see that the patient was not visiting the ED as often, she adds.

• Communicate with providers. “Have a thoughtful conversation with the physician,” Wilding suggests.

Case managers should keep information thorough, but succinct.

“You could say, ‘I reviewed Mrs. Smith’s chart, and here are the four conditions she has, and here’s what needs to be done to keep her out of the ER,’” she says.

When case managers create a reasonable task for the care team, it helps providers become engaged because they can see how the process works, she adds.

“This is instead of just saying, ‘I want to get Mrs. Smith into care management,’” Wilding says. “Saying just that doesn’t motivate them to engage, and this is all about engaging and building that relationship.”