“It's Tricky”: Care Managers' Perspectives on Interacting with Primary Care Clinicians

Abstract

Care management programs that facilitate collaboration between care managers and primary care clinicians are more likely to be successful in improving chronic disease metrics than programs that do not facilitate such collaboration. The authors sought to understand care managers' perspectives on interacting with primary care clinicians. Semi-structured qualitative interviews were conducted with care managers (n = 29) from 3 health systems in and around a large, urban academic center. Interviews were audio recorded, transcribed verbatim, and iteratively analyzed using a grounded theory approach. Care managers worked for health plans (14%), outpatient specialty clinics (31%), hospitals and emergency departments (24%), and primary care offices (14%). Care managers identified the primary care clinician as leading patients' care and as essential to avoiding unnecessary utilization. Care managers described variability in and barriers to interacting with primary care clinicians. When possible, care managers use the electronic medical record to facilitate interaction rather than communicating directly (eg, phone call) with primary care clinicians. The role of the care manager varied across programs, contributing to primary care clinicians' poor understanding of what the care manager could provide. Consequently, primary care clinicians asked the care manager for help with tasks beyond his/her role. Care managers felt inferior to primary care clinicians, a potential result of the traditional medical hierarchy, which also hindered interactions. Although care managers view interactions with the primary care clinician as essential to the health of the patient, communication challenges, variability of the care manager's role, and medical hierarchy limit collaboration.

Introduction

Care managers are health care professionals, commonly nurses or social workers, who assist patients with coordination of care, understanding their health conditions, and developing self-management skills.^1,2 Goals of care management include improving health status and minimizing unnecessary and costly health care utilization, though these goals may vary.^1–3 The increasing prevalence of chronic conditions and focus on population health has led to a proliferation of care management programs across the continuum of care,^4–7 making care managers increasingly present in care delivery.^8,9

The role of care managers in assisting with coordination of care and management of chronic conditions is complementary to the role of the primary care clinician in providing “first contact, continuous, coordinated and comprehensive care.”^10–12 Ideally, care managers gather information such as barriers to care, disease understanding, and medication adherence – knowledge and behaviors that are consequential to the care the primary care clinician provides.¹³ Analyses of key components of successful care management programs have shown repeatedly that effective collaboration between care managers and primary care clinicians is key to successful outcomes, but the barriers to and facilitators of collaboration between care managers and primary care clinicians are not completely understood.^3,14–16

Although others have evaluated primary care clinicians' perspectives on interacting with care managers,^15,17–21 care managers' perspectives on working with primary care clinicians have not been explored as robustly.^14,16,22 Evaluations that include care managers' perspectives focus primarily on understanding factors that lead to successful implementation of a care management program in a primary care practice, or the experience of becoming a depression care manager in a primary care practice.^14,16,22

Understanding the perspectives of care managers from across the continuum of care could inform the next generation of care management programs. Efforts to improve outcomes by targeting collaboration between primary care clinicians and care managers may fall short without understanding and incorporating the needs and preferences of care managers. This study was conducted to describe the perspectives of care managers who work across the health care continuum on their experience interacting with primary care clinicians.

Methods

This qualitative study involved conducting in-depth semi-structured interviews with care managers within the Baltimore metropolitan area. Care managers were recruited from a variety of settings across the care continuum, including health plans, emergency departments, inpatient hospitals, primary care offices, and specialty care offices. Many of the care managers worked for a large academic health system that included each of these settings and shared an electronic medical record.

Care managers were eligible to participate if they worked with adult patients, were affiliated with a program that was located in the Baltimore-Washington geographic area, and could provide informed consent. The study team stratified sampling by primary affiliation of the care management program to ensure representation from across the care continuum. Affiliation categories included: health plan, outpatient specialty (eg, HIV, advanced liver disease), primary care, hospital or emergency department, home health care, and other (private care management, regional collaborative of hospitals). The team identified eligible participants through a central list of care managers from a large academic hospital system and participant referral (snowball sampling), resulting in the inclusion of care managers from a total of 3 different health systems. Recruitment stopped when thematic saturation was reached. Each participant received a $30 gift card.

The interview guide was developed and pretested with 3 care managers. The interview guide sought to assess care managers' experiences interacting with all members of the care team – patients and any family or friends involved in their care, primary care and specialty care physicians, and other care managers. For the purposes of this analysis, the focus was on the responses pertaining to interactions with the primary care clinician. The specific prompt used was, “Tell me about your typical interactions with the primary care clinician,” although any information relevant to the topic was included, regardless of prompt. Probes and follow-up questions included clarifying the mode, frequency, and content of communication, and asking about barriers to and facilitators of collaboration.

Interviews were 40–60 minutes long and were conducted either in person or over the phone. Each interview was audio recorded and transcribed verbatim. At the conclusion of the interview, participants were asked to complete a short questionnaire that asked about sex, race, ethnicity, years in practice, training and credentials (eg, nurse, social worker), estimated average case load, estimated average length of relationship with a patient, and primary affiliation.

The study team used a grounded theory approach to code transcripts using Atlas.ti software (Atlas.ti Scientific Software Development GmbH, Berlin, Germany). Transcripts were analyzed in an iterative fashion, using a constant comparative analysis approach to generate and refine a coding template. Any revisions to the coding scheme were applied to all previously coded transcripts. Three independent coders (SN, AN, JL; working in pairs 2 at a time) independently applied the codes to transcripts. Differences were reconciled with discussion until consensus was reached. Content analysis generated themes and subthemes. This study was determined to be exempt from full review by the Johns Hopkins Institutional Review Board.

Results

A total of 29 care managers were interviewed (Table 1). The team identified 3 main themes with subthemes (Table 2).

Table 1.

Participant Characteristics (N = 29)

Characteristic	Number of Participants (%)*
Female	26 (90%)
Race†
White	17 (59%)
African American	7 (24%)
Asian	5 (17%)
Hispanic ethnicity	2 (7%)
Training‡
Nursing	26 (89%)
Social Work	3 (10%)
Other	1 (<1%)
Years of experience, mean (SD)	9 (6)
Primary affiliation
Health plan	4 (14%)
Outpatient specialty	9 (31%)
Primary care	4 (14%)
Hospital or emergency department	7 (24%)
Home health care	2 (7%)
Other§	3 (10%)
Estimated average caseload mean (SD, range)	84 (68, 13–200)
Estimated duration of typical patient case
<1 month	5 (17%)
1–6 months	14 (48%)
7–12 months	8 (28%)
>1 year	2 (7%)

^* Percentages may not total 100% because of rounding.

† Participants could choose more than 1 category.

‡ One participant completed a degree in nursing and social work.

§ Other included a private care management company (n = 1) and a regional collaboration of hospitals (n = 2).

SD, standard devation.

Table 2.

Major Themes and Subthemes with Example Quotes

Theme 1: Importance of the primary care clinician
Essential to health of the patient Key to decreasing inappropriate utilization Seen as the leader of the health care team	“Oh well the reason they are so sick is because they don't go to the primary care provider.” Primary Care-Based Care Manager
	“[A primary care clinician is] one of the major significant factors of the patient's success…we definitely encourage the patient to select a primary care doctor so that all their needs could be met… if they have acute issues they can go to that primary care doctor as opposed to going to the ED. So that is a really important question we ask the patient [who their primary care is]” Hospital-Based Care Manager (Emergency Department)
	“Most of these patients [don't] have a primary care physician or core rapport with their primary care doctor. Maybe they have ten doctors involved in their case but they don't have the primary doctor really coordinating everything and things get lost.” Hospital-Based Care Manager (Transitions of Care)

Theme 2: Variability in and barriers to interaction
Frequency, amount, and content of communication is variable The EMR facilitates communication, but only within a single health system Sharing documentation on the EMR and speaking with clinic staff more common than communicating directly with clinician	“Now when I was embedded in the clinic [communication with the PCP] was easy…in my current situation, it's a little tricky, because my patients are everywhere, there's no one specific clinic.” Hospital-Based Care Manager (Transitions of Care)
	“I'm in contact with the doctor's office for most clients quite often. Anytime there's a flare-up, whatever it is I let the physician know just so that they have it in their records.” Private Care Manager
	“I don't really have too many conversations with the doctors unless there's an issue. Sometimes it's really just with the office.” Health Plan Care Manager
	“Communicating with primary care providers if you're not sharing an EMR can be a daunting task.” Regional Collaborative of Hospitals Care Manager

Theme 3: Influence of care manager and primary care clinician roles on interaction
Poor understanding of care manager role Variability in care manager role Traditional medical hierarchy, view of PCP as “busy”	“Maybe they're not understanding what case managers do. They majority of the time I would say they will ask me to schedule appointments for a patient… which I don't mind, I do it a lot, but I can do more than that.” Primary Care-Based Care Manager
	“Because it's [the PCP's] patient, simple as that… They need to know who's interacting with their patient.” Health Plan Care Manager
	“I had one doctor that felt—they were so annoyed… I try to get them to understand that I'm here to help them too. I can tell that they're annoyed… it's like we're just another person that calls to ask for something… They don't see us as helping.” Regional Collaborative of Hospitals Care Manager

ED, emergency department; EMR, electronic medical record; PCP, primary care clinician.

Theme 1: Importance of the primary care clinician

Care managers from across the care continuum reported routinely asking patients who they see for primary care and about the quality of their relationship with the primary care clinician. Some care managers, particularly from acute care locations (hospitals, emergency departments) and from the regional collaborative of hospitals, stated that a goal of their role is connecting the patient with a primary care clinician the patient trusts.

“[My goals are] definitely getting them engaged with a primary care doctor. Lots of times they are disengaged so they need that, a new primary care doctor.” Regional Collaborative of Hospitals Care Manager

Regardless of primary affiliation, care managers referred to the primary care clinician as being a critical partner in helping to manage and prevent illness and decreasing unnecessary utilization. Care managers from primary care offices and acute care settings commented that patients who do not have a primary care clinician or who have a poor relationship with their primary care clinician are more likely to use the emergency department inappropriately (Table 2).

Care managers from all settings often referred to the primary care clinician as leading the patient's care. The primary care clinician was seen as having the overall view of the patient in mind and as responsible for setting the care plan. One primary care-based care manager explained that when specialists gave conflicting recommendations she would “go back to the primary and say, you know, ‘Give me some direction here.’”

Specialty care managers identified the importance of keeping the primary care clinician “in the loop” about care, because of potential implications for the patient's overall health.

Theme 2: Variability in and barriers to interaction

The frequency and content of interaction between care managers and primary care clinicians was variable. Regardless of the care manager's primary affiliation, interaction with the primary care clinician often was described as driven by the patient's needs rather than determined by protocol or routine. For example, some care managers reported communicating with the primary care clinician frequently because they viewed their observations of the patient as important for the clinician to know about. Other care managers communicated with the primary care clinician less frequently because they viewed their role as a care manager as more focused on social than medical issues. Specialty-based care managers interacted with the primary care clinician as needed based on changes to the patients' plan of care.

“I'm in contact with the doctor's office for most clients quite often. Anytime there's a flare-up, whatever it is, I let the physician know just so that they have it in their records.” Private Care Manager

“My notes aren't going to be beneficial one way or another [to the primary care clinician], because I'm not changing anything about the patient's medical modality… I'm just there to support it.” Regional Collaborative of Hospitals Care Manager

Many care managers interviewed, including those located in primary care clinics, reported relying on the electronic medical record (EMR) for most interactions. They described that the bulk of EMR interaction was sharing documentation that they (the care manager) completed in the EMR, rather than sending a direct message. Even when a direct message was sent, the primary care clinician did not respond consistently. The lack of response left some care managers unsure about whether they could count on the primary care clinician to address the issue.

Care managers from across the care continuum, described the ability to share their documentation or send a message through the EMR as “wonderful,” “great,” and “extremely convenient and secure.” However, this means of interaction was limited to clinicians who were in the same health system and thus shared the same EMR. Interaction with primary care clinicians who did not share an EMR was described as “daunting” and typically occurred only in the context of a problem with the patient rather than routine information sharing. In these situations, when care managers did make a phone call to the office, they frequently spoke with office staff instead of the primary care clinician.

“Sometimes [interaction] is really just with the office. I'll speak to the secretary or the nurse, nurse practitioner. But I would say we really don't have a lot of conversations with the physician.’” Health Plan Care Manager

Care managers stated that easier ways to interact with primary care clinicians were needed. One hospital transitional care manager noted that after she identified a discrepancy in a patient's discharge medication list, there was not a straightforward way to address the issue with either the discharging clinician or the primary care clinician. Similarly, another care manager from the regional collaborative of hospitals noted that she sometimes had to resort to driving to the primary care practice if she needed to get something done for a patient and previous messages had been unanswered. Engaging the primary care physician in ongoing dialogue was identified as a standard of practice in the field of care management and care managers reported that such ongoing dialogue “would be beneficial, of course.” However, barriers such as lack of a universal EMR, busy primary care clinics, and limited time on the part of the care manager because of a high caseload kept care managers from realizing this in practice.

Theme 3: Influence of care manager and primary care clinician roles on interaction

Care managers viewed their role as being primarily in support of the patient and secondarily in support of the primary care clinician. For example, if a care manager helped a patient improve medication adherence, the care manager helped that patient achieve better disease control and secondarily helped the primary care clinician carry out the care plan. An exception to this was specialty care managers, who viewed their role as in support of the specialist clinician and patient, which included keeping the primary care clinician informed about pertinent issues.

“When [my patients] don't understand something the doctor told them, I want them to feel they can absolutely call me and I'll be able to interpret it for them.” Primary Care-Based Care Manager

The role of care manager varied by type of employer and care team. Employers had different expectations of caseload, mode and frequency of communication with patients, and which patients were eligible to work with the care manager. Care managers often described themselves as assisting patients with needs that other members of the care team were not addressing. In many cases this meant care managers were helping with social issues such as connections to resources for transportation, housing, and food. However, if there was a social worker available on the care team, a care manager may be more focused on the “medical” tasks such as medication management and chronic disease self-management.

“[My previous role] was very much directed to the older population, knowing that they have all these comorbidities in addition to having a cancer diagnosis… [In my current role] it was taking a long time to get some people to surgery…filling in those needs is much different than being in geriatric oncology. So I think a lot of [the care manager role] depends on what the needs are and the population you are serving.” Outpatient Specialty Care Manager

“When it's housing or transportation or those things, social aspects, then they understand [I can] help them with that, because, the doctor is not able to or the nurse is not able to.” Outpatient Specialty Care Manager

Because of variability in the role, the bounds of the care manager role often were unclear to both care managers and to the primary care clinician. Care managers who were embedded in clinics were often asked to help with any patients, even if the patient did not meet the requirements of the program the care manager represented. Primary care clinicians asked care managers to assist with tasks such as scheduling appointments rather than tasks that were consistent with their expertise such as teaching disease self-management. Care managers often were asked to help with tasks that were related to a 1-time need, such as completing a form or identifying resources, rather than engaging patients in ongoing care management.

“I wish there was [sic] more concrete guidelines of who is supposed to be responsible for what…my job is considered ESRD [end-stage renal disease] case manager. Even within my own team that is very vague. Am I supposed to take care of just the ESRD-related [issues]? Or am I supposed to take care of anything and everything?” Outpatient Specialty Care Manager

“And sometimes it's frustrating…when the doctors say, ‘Oh can you look up this? Can you find this? This family wants caregiver help.’ Okay… I'm not going to open them up to case management, but I am going to spend quite a bit of time with them.” Primary Care-Based Care Manager

The traditional medical hierarchy was an implicit subtheme around the care manager and primary care clinicians' respective roles. Care managers often emphasized that they were “just” a nurse or social worker, not a prescribing clinician, and the patient was really the primary care clinician's patient. Specialty-based care managers did not feel it was their place to call the primary care clinician about changes to the care plan that needed monitoring by the primary care clinician and instead asked the specialist physician to communicate these changes. Further, the primary care clinician was generally described as extremely busy and care managers did not feel that the primary care clinician would necessarily welcome their contributions.

“[Primary care doctors are] not necessarily buying into all of this care management stuff. It's like, ‘What do you want?’… I know that they're very, very busy.” Health Plan Care Manager

Discussion

To the study team's knowledge, this is the first study to examine perspectives of care managers from across the continuum of care on their experiences interacting with primary care clinicians. This study finds that although care managers view the primary care clinician as essential to the health and success of the patient, communication challenges, variability of the care manager's role, and the medical hierarchy inhibit effective interaction, let alone true collaboration. Previous reviews of care management interventions have demonstrated that successful interventions include a clear and strong relationship between the primary care clinician and care manager; however, these reviews were not able to identify specific barriers to building such relationships.^3,14–16 Studies focused on incorporating care management into primary care have focused primarily on care management that is affiliated with the primary care practice, but not other practices or settings in which a care manager may work.^15,16 Present study results identify specific barriers to forming a strong relationship with the primary care clinician in care management programs from the perspectives of care managers who work across the continuum of care, and provide insights into opportunities to refine ongoing care management efforts.

The loosely-defined bounds of the care management role were found to reduce effective interaction with the primary care clinician. Care managers reported that primary care clinicians often asked them for assistance with tasks that were below the care manager's level of skill and expertise, thereby leading to missed opportunities for support for both the patient and primary care clinician. Patients in need of care management support may not be referred because the primary care clinician does not understand what a care manager can provide. Further, care of complex patients – for whom care management is designed – can be stressful for primary care clinicians because of inadequate resources.^23,24 The present study suggests that poor role definition is one impediment to building an effective care manager–primary care clinician partnership, and limits care management productivity.

Care managers described variable interactions with the primary care clinician. Many care managers described a lack of standard protocol for engaging the primary care clinician. Interaction was most common when there was a shared EMR, but often was reduced to sharing documentation on patient encounters rather than direct messaging. Interacting with primary care clinicians who did not share the same EMR was described as a significant barrier. This finding is notable because care managers work with complex patients who are known to access care from different providers and health systems that may not share the same EMR.^25,26 Further, presence of a shared EMR suggests a more integrated health system, which by design may facilitate better interactions and role understanding. Thus, care managers may spend a significant amount of time trying to obtain data from other providers or health systems, resulting in delays or inability to obtain important information (eg, medication change) for patient care.

This study demonstrates that communication is influenced by the medical hierarchy, and that care managers perceive themselves as below the primary care clinician. This finding is in opposition to the recommended “flat hierarchy” (in which each team member is empowered to speak up), which has been demonstrated to be a critical feature of effective teamwork and communication in health care.²⁷ Further, the present study found that much of the communication described is indirect or unidirectional, whereas closed-loop communication is considered to be a critical feature of effective communication.²⁷ Challenging the traditional medical hierarchy and developing effective communication patterns are important team-based skills that require substantial investment early on to achieve.^28–30 The failure to achieve foundational elements of team-based care may reflect that creation of programs is outpacing clinical practices' ability to adapt.²⁸ A potential solution to poor care manager and primary care collaboration may be investment in team training.

This study has limitations. First, the care managers interviewed were in a single urban geographic region and thus study results may not be transferrable to other locations. Second, because care managers were asked to describe their opinions of physicians and to describe their routine practice in interacting with primary care clinicians their responses may be prone to social desirability biases, or the desire to say the socially acceptable thing in an interview. However, many care managers were candid about their limitations in interacting with primary care clinicians. Third, although this study identified potential barriers to meaningful interactions with primary care clinicians from the perspectives of care managers, it was not designed to determine whether addressing those barriers will improve the care manager primary care clinician relationship or patient outcomes. Further research is needed to understand which targeted interventions will result in improved collaboration and patient outcomes.

Taken together, the study results suggest that although care managers' and primary care clinicians' roles in care coordination, chronic disease management, and first contact care are complementary, they more often occur in parallel than together. Regardless of the care managers' primary affiliation, they are collecting information about patients that could be valuable to the primary care clinician.^1,31 As the number of care managers across the health care continuum increases and patients are more likely to come into contact with a care manager, it will be important to improve collaboration and communication with the primary care clinician, who has been described as the “quarterback of the team.”³²

Author Disclosure Statement

Dr. Boyd reports receiving royalties from UpToDate. All other authors have no conflicts of interest.

Funding Information

Grants for Early Medical/Surgical Subspecialists' Transitioning to Aging Research (GEMSSTAR) National Institutes on Aging R03 AG060170-01 (Dr. Nothelle); National Institutes on Aging K24AG056578 (Dr. Boyd); Medical Student Training in Aging Research (MSTAR) National Institutes on Aging T35AG026758 (Ms. Litman).