Academic journal article Care Management Journals

Geriatric Case Managers: Integration into Physician Practices

Academic journal article Care Management Journals

Geriatric Case Managers: Integration into Physician Practices

Article excerpt

Integration of case management proved to be a key variable in a national demonstration at nine sites of alternative models designed to enhance primary care of frail elders. Numerous semistructured interviews of participants revealed a number of areas important to achieving successful integration. These areas include making favorable first impressions, building relationships, learning to collaborate, having proximity and contact, communicating, and demonstrating benefits to patients and physicians.

Primary health care for frail elders should be a coordinated, multidisciplinary process that reacts not only to medical conditions, but also addresses underlying psychosocial, economic, family, community support, and home environment issues that affect patients' health and their ability to function. Much attention has been focused on primary physician care of elderly patients (Institute of Medicine, 1996; Mark, Gottlieb, Zellner, Chetty, & Midtling, 1996; Radecki, Kane, Solomon, Mendenhall, & Beck, 1988; Sofaer, 1998; Weiss & Blustein, 1996), and there is a rapidly expanding literature on case management (see, for example, the many articles in the Journal of Case Management.) Specifically, geriatric case management is increasingly becoming recognized as an important component of chronic care (Applebaum & Austin, 1990; Capitman, Haskins, & Bernstein, 1986; Gerber, 1994; Geron & Chassler, 1994; Kane, Penrod, & Kivnick, 1994; Like, 1988; Netting & Williams, 1995). Attempts to understand how physicians cope with older persons who present with multiple problems (Kaufman, 1995) and collaborate with other professionals who perform case management functions (Netting & Williams, 1996) are the subject of recent studies.

Yet, amid the growing literature, the sheer interest in the topic and the recent empirical data are basic, practical concerns mentioned repeatedly by practitioners in the health care field: How does one integrate case management into physician practices? What exactly does one need to know, to do, and to reinforce in order for integration to truly occur? How do multidisciplinary relationships develop, and are they valuable to physicians and their older patients?

Our purpose is to share what was learned in a multiyear, multisite initiative funded by The John A. Hartford Foundation. Beginning with a brief overview of the project and the methods used to collect and analyze data, we focus on those factors that emerged as essential in integrating case managers into busy physician offices. We conclude with a list of suggested questions for inclusion in an initial assessment by persons interested in introducing case management into a primary physician's office practice.

THE DEMONSTRATION PROJECT INTERVIEWS

In 1992 The John A. Hartford Foundation funded a 5-year initiative designed to improve approaches to caring for frail elderly persons. In eight geographically dispersed sites throughout the United States, physicians worked in tandem with other professionals (e.g., social workers, nurses, nurse practitioners, physicians' assistants) or paraprofessionals who performed basic case management functions. At the ninth site, physicians served as their own case managers using self-reported assessment data. Project sites varied in setting, organization, allied personnel, methods of operation, and other factors. Each site represented an alternative model for enhancing the care of community-based older persons by primary physicians (for an overview of each project, see Netting & Williams, 1999).

The study included regular visits by us to each site to identify unique and common factors that contributed to project success. We developed a semistructured interview schedule to allow flexibility for respondents to elaborate and to allow us to probe and clarify when new information emerged (Fontana & Frey, 1994). In 1994, we conducted 105 face-to-face, taped interviews. …

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