Population-Based Case Management at Southcentral Foundation

Previous articles on this blog have discussed Southcentral Foundation’s Integrated Care Teams, which consist of a primary care provider, certified medical assistant, case management support and nurse case manager. Within the integrated care teams, case managers at SCF have multiple roles and practice standards. They ensure continuity of care and build relationships with customer-owners, which help them support positive behavioral change, encourage self-care and benefit the overall wellness of customer-owners. Many case managers have had the same panel of customer-owners for 5 to 10 years or more.

SCF views accessibility and responsiveness as critical parts of a case manager’s responsibilities. Since SCF has an open-access system where a customer-owner can get an appointment on demand, often on the same day it is requested, most of the demand needs to be addressed by the case manager in a timely manner so that provider schedules remain manageable. Case managers are easily accessible to customer-owners by phone and email.

Some other responsibilities of case managers include:

• Disease management. This includes both preventative care (e.g., cancer screenings) and chronic care (e.g. diabetes and hypertension management). SCF’s data tracking services create action lists to assist with this type of management.
• Triage of incoming customer-owners. A customer-owner may access the health care system (either in person or on the phone) for a particular issue, and the case manager uses that opportunity to evaluate the wellness of the whole person. This encompasses not only their current acute need, but their preventative and chronic needs as well.
• Ensuring that plans of care are followed and updated as needed.
• Helping customer-owners navigate the health care system. This can include referral to other health resources, either internal or external to SCF, if needed.
• Connecting with the provider and the rest of the care team on a regular basis to ensure that needed care is being delivered and customer-owners are properly supported.

Case managers are a key part of SCF’s Nuka System of Care, and they work in partnership with customer-owners to help them achieve wellness.

If you are interested in more information, contact us for further resources on this topic, such as the full job description of SCF’s RN Case Manager.