Case Management in Primary Care

Core Assessment and Planning Functions

The American Heart Association identifies that case managers conduct comprehensive needs assessments across medical, psychological, functional, and social domains when patients enter the primary care system, which includes identifying appropriate levels of care and required resources, unmet medical and non-medical needs, and barriers to care such as lack of adequate food or safe housing 1, 2, 3, 4
Case managers develop individualized service plans that address all identified needs, with active patient and family participation in the planning process, as recommended by the American College of Cardiology 1, 2, 3

The American Heart Association recommends that case managers coordinate care and referrals across multiple providers and settings, including hospital, home, and community, and integrate input from all physicians and ancillary providers when multiple specialists are involved 1, 2, 3
Case managers oversee population health management within health systems, as suggested by the American Heart Association 1

The American Geriatrics Society emphasizes that case managers link patients to organizational and community resources, including social services, disease management programs, and community outreach programs, and facilitate access to the health care system, particularly for vulnerable populations 1, 3, 4, 5
Case managers enable access to social services and community health workers, as recommended by the American Heart Association 1

Case managers maintain ongoing oversight of care delivery, monitoring and evaluating service provision and costs to ensure appropriate resource allocation, and track patient progress and adjust care plans as needs change, as suggested by the American College of Cardiology 2, 3
Case managers serve as patient advocates, ensuring patients receive appropriate services and have their needs met, as recommended by the American Geriatrics Society 2, 3

The American Heart Association/American Stroke Association found that effective case management models include advanced practice clinicians who are part of or in close communication with primary care teams, meet personally with patients, and have prescription authority, which improves medication adherence and achieves better control of hypertension and diabetes 6, 7
Case managers oversee case management activities for patients at risk for excessive resource usage or suboptimal outcomes, as suggested by the MMWR Recommendations and Reports 8

Case managers work alongside physicians, nurses, pharmacists, social workers, nutritionists, and behavioral health experts, as recommended by the American Heart Association, and maintain regular office rounds to maintain visibility, discuss cases, and educate staff about patient risk factors 1, 5
Case managers promote guidelines and meet quality and performance metrics at the organizational level, as suggested by the American College of Cardiology 1

Research evidence shows that case managers in primary care achieve increased services and reduced unmet needs for patients, improved patient confidence in receipt of care and life satisfaction, as found by the Praxis Medical Insights 2, 3
The Infectious Diseases Society of America found that having an HIV team that includes a case manager frequently enhances adherence to care and engagement, demonstrating the value across disease states 4

The American Geriatrics Society states that case managers serve as coordinators and facilitators, not directors of medical decision-making, and medical guidance must always remain under the authority of the primary care provider 9, 10
Primary care providers retain full authority over medical decisions, while case managers coordinate services, assess needs, and facilitate communication—but do not supersede clinical judgment 9, 10, 11, 12, 13
Care management assessments and care plans must be available to and approved by the primary care provider 9, 10

The American College of Physicians describes three levels of integration: coordinated care, colocated care, and integrated care, none of which position case managers as directors of medical care 14
In integrated care models, clinicians act together to design a unified patient care plan, but medical decisions remain with licensed providers 14

Case managers are responsible for maintaining communication and coordination with other providers, but do not direct their clinical decisions 11, 12, 13
The American Geriatrics Society warns that case managers who also provide services or work for organizations that provide services may have conflicts of interest 9, 10

Patients and families must participate actively in formulating individual care plans, and case managers empower patients in determining what services are offered and chosen 9, 10
When a particular service is denied, terminated, or restricted, patients must be informed promptly and given the right to appeal 9, 10