A role for case managers in the physician office.

Independent primary care physicians continue to be important gatekeepers for health care services needed by older patients. There is a natural role for case management in the physician office as a link to nonmedical support services that can help the elderly maintain their independence. In this article, the authors describe a model partnership between primary care physicians and a community-wide case management program that was developed to enhance the continuum of care and improve integration of service systems. Rapid response for assessments, brief interventions, and linkage to home and community services are provided through a case manager/liaison who is on-call to physician offices. Patients are seen in the physician office or in their homes or contacted by telephone. The liaison assesses and provides immediate information and referral, maintains short-term contact, or refers patients with complex situations or long-term case management needs to agency or community case management programs. The liaison also makes regular office rounds to maintain visibility, discuss cases, and educate staff about patient risk factors. Physicians and patients have been pleased with the model.