Executive Summary
Recognizing that there are patients who need a lot of support in managing their conditions and optimizing their health, healthcare systems and health plans are embedding case managers in primary care practices.
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Case managers in primary care have the time and expertise to educate patients about their conditions and support them in following their treatment plans.
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Organizations with case managers on staff report an increase in preventive care and lower healthcare costs for patients who work with the case manager.
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CCase managers have the satisfaction of developing relationships with patients and seeing patients progress over time.
New opportunities are opening up for case managers in primary care as physician practices, healthcare systems, and health plans recognize the value of care coordination.
Primary care practices, especially large physician practices and community clinics, are looking at integrating RN case managers and social workers into their practices, says Cheri Lattimer, RN, BSN, executive director of the Case Management Society of America (CMSA).
"Physicians are recognizing that case managers can take the role of advocate, improve care coordination and communication, and support the patient as they move through the continuum of care," she says.
Primary care offers a great opportunity for case managers to work with patients and their family caregivers and help them gain the skills to manage their healthcare resources and be self-sufficient, she adds.
"There is definitely a role for case managers in primary care to manage the sickest of the sick and do targeted population management," says Mary Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group, a division of Sentara Healthcare System, which operates throughout Virginia and northeastern North Carolina.
Sentara Healthcare System redesigned its primary care case management program and now has embedded case managers in 38 primary care practices. The case managers have an office in each practice to which they are assigned and schedule their time at each practice. In the first three years, the total cost of care dropped by 17% over a three-year period and all-cause readmissions dropped by 21% for patients in the program. (For details, see related article on page 123.)
The number of case managers in primary care practices is on the increase as healthcare systems and insurance companies embed case managers in the practices to identify and coordinate care for patients who are frequent utilizers of the healthcare system, says Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY-based case management consulting firm.
There are a lot of benefits in having a case manager in a physician practice, especially if the practice is part of an accountable care organization, Mullahy says. "If there is a set number of dollars to manage everybody and some patients are using the bulk of the resources, it make sense to have someone who can work with those patients to help them learn to manage their own healthcare," Mullahy says.
Case managers in primary care are the physician’s partner, Mullahy says. "They have the ability and skill to take the time needed to talk with patients and family members. They have the clinical expertise and skills to work with people," she says.
Care coordinators provide a pivot point between the patient, the health plan, and the physicians and nurses in the primary care practices that are part of Cigna’s collaborative accountable care initiative, says Harriet Wallsh, RN, director of Cigna collaborative care clinical operations in Orlando, FL. The care coordinators in the physician practices are employed by the practices and work closely with Cigna case managers to make sure patients get the services they need, she adds.
"Care coordinators are an important component in meeting our goals of improving quality, affordability, and the experience of care," she says. (For details of how the care coordination process works at one practice aligned with Cigna, see related article on page 125.)
Population care coordinators are a key part of Horizon Blue Cross Blue Shield of New Jersey’s patient-centered physician practice initiative, according to Steven Peskin, MD, MBA, FACHE, senior medical director, clinical innovations for Horizon Blue Cross Blue Shield of New Jersey.
The population care coordinators focus on the top 5% to 10% of patients who are sickest but who potentially can control their conditions. They work at the individual practices and meet patients in person as well as corresponding via telephone, email, and text messages. (For details, see related article on page 126.)
When case managers work in primary care practices, it’s a win-win-win situation, Mullahy adds.
The patients get the help they need in managing their conditions and maximizing their health. Physicians have someone on their staff who has the time and expertise to give patients the support they need to follow their treatment plan, and case managers benefit because they can do what they went into nursing to do — make a difference in people’s lives, she adds.
Unlike hospital-based case managers who see their patients in the hospital and lose touch when patients are discharged, case managers in primary care develop long-term relationships with patients, Mullahy points out.
"Case managers in primary care are managing a small group of people who really need their help. The case managers are able to experience what most of us envisioned case management to be. They provide a relationship-based model of care and really make a difference," she says.
