Care coordination vs. case management: What's the difference?
Although there is significant overlap, care coordination and case management are distinct in their scope of practice.
Jobs like care coordination and case management have come to the forefront as healthcare has continued its embrace of value-based care.
In pursuit of better outcomes at a lower cost, many healthcare organizations have invested heavily in patient-centered care and social services aimed at improving overall patient health and well-being. By addressing chronic care and social determinants of health (SDOH) needs, industry experts posit that patients can stay healthier and avoid high-cost episodes of care.
To achieve that vision of better health and well-being, most experts agree care coordination and case management are necessary.
Both care coordination and case management seek to streamline and simplify what is typically a complex healthcare journey for patients. For example, care coordination and case management might ensure smooth hospital discharge activities and help patients access follow-up care and social services.
But how exactly are care coordination and case management defined? And are they two different things, or are the care coordinator and case manager the same role?
Indeed, the literature acknowledges the overlapping nature of care coordination, case management and other related fields, like patient navigation.
"Case management is often a part of other healthcare activities embodied in terms such as care management, care coordination, and disease management," according to an article in StatPearls. "All these terms have overlapping definitions and identities. Case management is a fundamental element of these other activities."
Still, most experts acknowledge that there are some distinctions between care coordination and case management, including in scope of practice.
Defining care coordination
According to HealthCare.gov, care coordination is "the organization of a patient's care across multiple health care providers."
Care coordination is essential because most patients see more than one healthcare provider across their lifespan and even across a single episode of care. Either way, ensuring coordination and communication across all healthcare providers is essential, according to CMS.
"When health care providers don't communicate effectively with each other around a patient's care, resulting in -- for example -- repeated lab tests, drugs that don't work when you take them together, more trips to the doctor's office that could have been handled with a phone call, and other negative impacts that lead to confusion and higher out-of-pocket costs for patients," CMS says.
Lack of care coordination can make for a bad healthcare experience and increase healthcare costs.
Conversely, when healthcare providers talk to each other and share health information, they can provide safe, appropriate and effective healthcare, CMS says.
All patients benefit from good care coordination, but according to CMS, care coordination is particularly crucial during the following situations:
- Follow-up after an emergency department (ED) visit.
- Care between a primary care provider and specialists.
- A temporary stay in a skilled nursing facility.
- Transitions of care.
Healthcare organizations might hire individuals to focus solely on care coordination as part of a care coordination team. However, smaller healthcare organizations might put nurses in charge of care coordination.
These individuals make sure every member of a patient's clinical care team has the health information necessary to administer care. They also set up communication systems for these healthcare providers. In doing so, the care coordinator makes sure all clinicians are aligned on the patient's treatment plan, whether that plan be episodic or long-term for a chronic illness.
Care coordination hinges on interoperable health IT. In order for care to be coordinated across disparate providers, clinicians need access to interoperable EHRs and health information exchanges (HIEs). Care coordination software, patient engagement tools, population health management tools, and telehealth platforms are also helpful. All or some of these technologies are often part of an enterprise EHR product.
Systems that have limited interoperability will seriously hamper care coordination efforts. For example, poor integration between remote patient monitoring (RPM) tools and EHRs renders any patient-generated health data from the RPM tools moot, as the clinician can't see that data anyway.
As medical professionals have increasingly acknowledged the role SDOH play in health and well-being, many have found that social services are also in need of coordination. For some healthcare organizations, this role falls to the care coordinator.
However, the recent emphasis on SDOH and social services referral has also led to much of the overlap between care coordination and case management.
Defining case management
According to the Case Management Society of America (CMSA), case management is "a service offered by medical professionals to help individuals and their family caregivers manage their health needs," the organization says.
"Case management professionals seek to assist patients to receive the care they need to manage their diagnosis, illness or injury. They may also provide the support necessary to connect individuals to the right doctors, resources, education and services."
CMSA said that case managers can be called discharge planners, life coaches, patient navigators, population health managers, social workers or care managers. This variability in job titles can contribute to the confusion and conflation of care coordination and case management.
However, experts indicate that case management is broader in scope than care coordination.
Indeed, the StatPearls write-up indicates that care coordination is a narrower version of case management focusing on the clinical aspects of the healthcare journey or care episode. Communication between care teams, interoperable health IT systems and team-based care practices are core to care coordination.
Case management is broader, the StatPearls article suggests.
In particular, SDOH efforts fall more neatly under the case management umbrella. Individuals focused on case management might help coordinate interventions from healthcare providers in addition to SDOH and social services necessary to support health and well-being outside the healthcare setting, according to the Commission for Case Manager Certification (CCMC).
"The practice of case management is professional and collaborative, occurring in a variety of settings where medical care, mental health care, and social supports are delivered," the CCMC says. "Services are facilitated by diverse disciplines in conjunction with the care recipient and their support system. In pursuit of health equity, priorities include identifying needs, ensuring appropriate access to resources/services, addressing social determinants of health, and facilitating safe care transitions."
Because case management is more long-term and broader in scope, a case manager will organize not just clinical care, but also insurance paperwork and social services access.
For example, a Medicaid beneficiary who is housing insecure might need help filling out insurance forms and accessing affordable housing programs from a case manager. This would be separate from any relevant clinical care coordination that the individual needs.
Case managers often need a similar set of tools as their care coordinator counterparts, including EHR access and HIPAA-compliant patient engagement and messaging tools. Case managers will also need tools to help them collect and analyze SDOH data, look at social services referral databases and make referrals to services.
In addition to access to key tools, case managers need a number of soft skills that make it easier for them to do their jobs.
Many case managers work with clinically and socially complex patients, making empathy and lived experiences necessary for building rapport and patient trust. Cultural competence, conflict resolution and patient-provider communication skills, such as motivational interviewing, will also help case managers better connect with patients and clients.
Ultimately, both care coordination and case management seek to simplify the healthcare experience and ensure patient access to care. Depending on organizational resources, individuals might focus on clinical care coordination and clinician communication.
However, as more organizations work to address not just clinical needs but SDOH needs as well, a more encompassing case management approach might be needed.
Larger, resource-rich organizations might have the personnel to hire for two distinct roles. However, it could be that an organization employs a single individual or team to do general case management, ranging from SDOH work to care coordination.
Sara Heath has covered news related to patient engagement and health equity since 2015.
