A role for case managers in the physician office

Area of Science:

• Geriatric Medicine
• Health Services Research
• Community Health

Background:

• Independent primary care physicians serve as crucial gatekeepers for elder healthcare.
• Case management integration within physician offices can link seniors to vital nonmedical support services.
• Enhancing the continuum of care and service system integration is essential for older patients.

Observation:

• A model partnership was developed between primary care physicians and a community case management program.
• A dedicated case manager/liaison provides rapid assessments, brief interventions, and referrals to home and community services.
• The liaison operates on-call to physician offices, seeing patients in-office, at home, or via telephone.

Findings:

• The liaison offers immediate information and referral, short-term support, or long-term case management referrals.
• Regular office rounds by the liaison facilitate communication, case discussion, and staff education on patient risk factors.
• Physicians and patients reported high satisfaction with the implemented model.

Implications:

• This model demonstrates a successful strategy for integrating community resources into primary care settings for older adults.
• Improved coordination of nonmedical support services can enhance the ability of elderly patients to maintain independence.
• The partnership model offers a scalable solution for strengthening healthcare service delivery for aging populations.