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Integrating geriatric case management into primary care physician practices.

As the delivery of health and human services has become more complicated, fragmented, and expensive, case management has gained popularity. Various case management models have emerged in social work (Loomis, 1987), nursing (Gerber, 1994; Swindle, Weyant, & Mar, 1994), and medicine (Like, 1988). Multiple population groups are being served, and practice guidelines have been published (Geron & Chassler, 1994; Kaye, 1992). Geriatric case management targets frail clients who are at risk of being high consumers of health care services. Case managers who work with elderly clients often come into contact with primary care physicians and a plethora of other health care providers. The case manager's involvement may vary from just knowing the name of the client's physician to being directly involved in the physician's practice (White, Gundrum, Shearer, & Simmons, 1994). Relationships between physicians and social workers have been studied as an acute care interaction with discharge planning elements (Mizrahi & Abramson, 1994). However, as health care services move more and more into community-based settings, the potential conflict and need for collaboration between social work case managers and physicians also move. Some group practices are using social workers (Kramer, Fox, & Morgenstern, 1992). In addition, nurses, physician's assistants, and other health care personnel are assuming expanded roles in geriatric case management. Relationships between social workers and physicians date back to the early years of the profession. In 1919 the physician who appointed the first full-time paid social worker at Massachusetts General Hospital reported, "I needed information about the patient which I could not secure from him as I saw him in the dispensary - information about his home, his lodgings, his work, his family, his worries, his nutrition" (Cabot, cited in Mullaly, 1988, p. 5). This description reveals acknowledgment of the physician's need to view the person in his or her environment and the importance of the social worker's role in assessing home- and community-based factors. Today older people continue to turn to primary care physicians for assistance with their concerns and problems. However, cost pressures and the growth of managed care limit the time physicians can spend with patients. As physicians encounter more and more older patients, they often question just how far the scope of their medical practice extends into the broader social, economic, and environmental problems of their patients. It is too easy for physicians to limit their attention to monthly 15-minute office visits that are focused on medications to relieve symptoms. It is out of such changing and complex health care environments that demonstration projects emerge. The project reported here reflects the larger issues of health care delivery and the potential for collaboration between physicians and geriatric case managers. PROJECT Background In 1992 the John A. Hartford Foundation's Generalist Physician Initiative was started. Between 1992 and 1993, nine demonstration sites were funded across the United States. These projects were designed to enhance primary care physicians' care of frail elderly people by integrating geriatric case managers and caregivers into their practices. Although each site was required to have a well-designed evaluation, it was not mandated that each site use identical tools to measure outcomes or select patients in exactly the same way. Each site designed its own intervention; for example, in New Hampshire physicians were supported with educational resources so that they could become their own case managers, and in other projects various professionals (nurses, nurse practitioners, social workers, physician assistants, and paraprofessionals) acted as intervention agents. Depending on the credentials of each agent, roles and responsibilities varied. For example, nurse practitioners in inner-city Detroit remained clinic based, whereas paraprofessionals in South Carolina visited rural elderly people in their homes. …