Care Management for Older Adults: The Roles of Nurses, Social Workers, and Physicians
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Abstract
In the realm of healthcare, care management programs have gained significant traction, aiming to enhance the coordination and seamless integration of services for frail elderly individuals across the care continuum. Various care models advocate for the involvement of registered nurses (RNs) and social workers to facilitate these endeavors. A national survey conducted in 2018 encompassing 410 clinicians from 363 primary care and geriatrics practices specializing in frail elderly care revealed that nearly 40 percent of these practices lacked either social workers or RNs. However, in practices where both types of providers were present, social workers were observed to be more actively engaged in conducting social needs assessments, while RNs took a lead role in care coordination. Interestingly, the level of physician involvement in social needs assessment and care coordination witnessed a noticeable decline when social workers, RNs, or both were part of the practice setup
References
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2. Hong CS, Abrams MK, Ferris TG. Toward increased adoption of complex care management. N Engl J Med. 2014;371(6):491– 3.
3. Ferris TG, Weil E, Meyer GS, Neagle M, Hefferman JL, Torchiana DF. Cost savings from managing high-risk patients. In: Yong PL, Sanders RS, Olsen L, editors. The healthcare imperative: lowering costs and improving outcomes: workshop series summary. Washington (DC): National Academies Press; c 2010. p. 301– 9.
4. Goodell S, Bodenheimer T, Berry-Millett R. Care management of patients with complex health care needs [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2009 Dec [cited 2019 Apr 26]. (Policy Brief No. 19). Available for download from:
5. Donelan K, Barreto EA, Michael CU, Nordby P, Smith M, Metlay JP. Variability in care management programs in Medicare ACOs: a survey of medical directors. J Gen Intern Med. 2018;33(12):2043– 5.
6. Blumenthal D, Chernof B, Fulmer T, Lumpkin J, Selberg J. Caring for high-need, high-cost patients—an urgent priority. N Engl J Med. 2016;375(10):909– 11.
7. Bodenheimer T, Bauer L. Rethinking the primary care workforce—an expanded role for nurses. N Engl J Med. 2016;375(11):1015– 7.
8. Sinsky CA, Sinsky TA, Althaus D, Tranel J, Thiltgen M. “Core teams”: nurse-physician partnerships provide patient-centered care at an Iowa practice. Health Aff (Millwood). 2010;29(5):966– 8.
9. Gunderson JM, Wieland ML, Quirindongo-Cedeno O, Asiedu GB, Ridgeway JL, O’Brien MW et al. Community health workers as an extension of care coordination in primary care: a community-based cosupervisory model. J Ambul Care Manage. 2018;41(4):333– 40.
10. Rowe JM, Rizzo VM, Shier Kricke G, Krajci K, Rodriguez-Morales G, Newman M et al. The Ambulatory Integration of the Medical and Social (AIMS) model: a retrospective evaluation. Soc Work Health Care. 2016;55(5):347– 61.
11. Barber RD, Coulourides Kogan A, Riffenburgh A, Enguidanos S. A role for social workers in improving care setting transitions: a case study. Soc Work Health Care. 2015;54(3):177–92.
12. Damio G, Ferraro M, London K, Pérez-Escamilla R, Wiggins N. Addressing social determinants of health through community health workers: a call to action [Internet]. Hartford (CT): Hispanic Health Council; 2017 Dec [cited 2019 Apr 26]. (Policy Brief). Available from:
13. McWilliams JM, Chernew ME, Landon BE. Medicare ACO program savings not tied to preventable hospitalizations or concentrated among high-risk patients. Health Aff (Millwood). 2017;36(12):2085– 93.
14. Hsu J, Price M, Vogeli C, Brand R, Chernew ME, Chaguturu SK et al. Bending the spending curve by altering care delivery patterns: the role of care management within a Pioneer ACO. Health Aff (Millwood). 2017;36(5):876– 84.
15. Bureau of Labor Statistics. May 2017 national occupational employment and wage estimates: United States [Internet]. Washington (DC): BLS; [last modified 2018 Mar 30; cited 2019 Apr 26]. Available from:
16. Figueroa JF, Joynt Maddox KE, Beaulieu N, Wild RC, Jha AK. Concentration of potentially preventable spending among high-cost Medicare subpopulations: an observational study. Ann Intern Med. 2017;167(10):706– 13.
17. The survey questionnaire is available at:
18. Donelan K, DesRoches CM, Dittus RS, Buerhaus P. Perspectives of physicians and nurse practitioners on primary care practice. N Engl J Med. 2013;368(20):1898– 906.
19. Viswanathan M, Kraschnewski J, Nishikawa B, Morgan LC, Thieda P, Honeycutt A et al. Outcomes of community health worker interventions [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; 2009 Jun [cited 2019 Apr 26]. (AHRQ Publication No. 09-E014). Available from:
20. Ganguli I, Orav EJ, Weil E, Ferris TG, Vogeli C. What do high-risk patients value? Perspectives on a care management program. J Gen Intern Med. 2018;33(1):26– 33.
21. Institute of Medicine. Retooling for an aging America: building the health care workforce. Washington (DC): National Academies Press; 2008.
22. Spetz J, Dudley N. Consensus-based recommendations for an adequate workforce to care for people with serious illness. J Am Geri Soc. 2019;67(S2):S385– 99).
23. Meyers D, LeRoy L, Bailit M, Schaefer J, Wagner E, Zhan C. Workforce configurations to provide high-quality, comprehensive primary care: a mixed-method exploration of staffing for four types of primary care practices. J Gen Intern Med. 2018;33(10):1774– 9
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Dec 19, 2022
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Mersal Majed Mersal Aldfery Walid Mazal Dhafaida Al-Salbi Naif Zaidan Suleiman Alanzi Faisal Rumaidh Mahthaf Aldhfeeri Salem Khalaf Sulaiman Albanaqi Rwem Essa Aljmily. (2022). Care Management for Older Adults: The Roles of Nurses, Social Workers, and Physicians. Journal of Population Therapeutics and Clinical Pharmacology, 29(04), 1005-1009. https://doi.org/10.53555/jptcp.v29i04.5642
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How to Cite
Mersal Majed Mersal Aldfery Walid Mazal Dhafaida Al-Salbi Naif Zaidan Suleiman Alanzi Faisal Rumaidh Mahthaf Aldhfeeri Salem Khalaf Sulaiman Albanaqi Rwem Essa Aljmily. (2022). Care Management for Older Adults: The Roles of Nurses, Social Workers, and Physicians. Journal of Population Therapeutics and Clinical Pharmacology, 29(04), 1005-1009. https://doi.org/10.53555/jptcp.v29i04.5642