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Care (Case) Manager

2.jennifersencenter_sierra_good-1_300To be successful, a program must have active care management, which is more than just getting the right people to the right services. It’s monitoring progress and ensuring that changes are effected when needed. Traditionally, the care manager coordinates behavioral and medical visits and services within the primary care site, ensuring that clients receive the treatment they need and that treatment plans involving multidisciplinary involvement are carried out with appropriate linkages. As the mental health system embraces the psychosocially-based recovery model to an ever greater degree, some clinics have extended care management beyond the scope of their own clinics, ensuring that clients are made aware of outside resources and making appropriate referrals to other agencies and organizations in a position to help them.

The care manager’s role in the IMPACT model focuses on monitoring the client’s progress, via repeated standardized assessments, to evaluate the effectiveness of current treatment, and recommending changes in medication regimen and/or psychotherapy approaches if established improvement thresholds have not been met. See Stepped Care.

Care Coordinator Job Description

Though the role of care coordinator was found to be an essential ingredient in integrated care, there is a lack of consensus about what the job specifically entails.  The following, taken from the Commonwealth’s “Reducing Care Fragmentation: A Tool Kit for Coordinating Care”, offers one job description:

Referral and transition coordination includes the following activities:

  • Maintain ongoing tracking and appropriate documentation on referrals to promote team awareness and ensure patient safety. This tracking may use an IT database.
  •  Ensure complete and accurate registration, including patient demographic and current insurance information.
  • Assemble information concerning patient’s clinical background and referral needs.
  • Per referral guidelines, provide appropriate clinical information to specialist.
  • Contact review organizations and insurance companies to ensure prior approval requirements are met. Present necessary medical information such as history, diagnosis and prognosis. Provide specific medical information to financial services to maximize reimbursement to the hospital and physicians.
  • Review details and expectations about the referral with patients.
  • Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g., request interpreters as appropriate, transportation services or prescription assistance).
  • Be the system navigator and point of contact for patients and families, with patients and families having direct access for asking questions and raising concerns. May assume advocate role on the patient’s behalf with the carrier to ensure approval of the necessary supplies/services for the patient in a timely fashion.
  • Identify and utilize cultural and community resources. Establish and maintain relationships with identified service providers.
  • Ensure that referrals are addressed in a timely manner.
  • Remind patients of scheduled appointments via mail or phone.
  • Ensure that patient’s primary care chart is up to date with information on specialist consults, hospitalizations, ER visits and community organization related to their health.

The following experience and skills may be important:

  • • High school diploma, sometimes combined with medical assistant certification
  • • Strong customer service focus
  • • Effective verbal and written communication skills
  • • Teamwork orientation
  • • Organized and able to manage competing priorities
  • • Good judgment
  • • Resourcefulness in problem solving
  • • Able to take and follow through with delegated tasks and accountability

An example of a job description for a Depression Care Manager, taken from the IMPACT model and furnished by Cherokee Systems in Tennessee is as follows:

The depression care manager educates patients about depression and its treatment, provides behavioral activation, monitors depressive symptoms and response to medication and/or psychotherapy using a structured instrument (e.g., the PHQ-9), works closely with the primary care provider and a consulting psychiatrist to revise the treatment plan when patients are not improving, and offers a brief course of counseling for depression (e.g., Problem Solving Treatment in Primary Care.

Duties and Responsibilities

  1. Conducts assessment of patient, including completion of the Patient Health Questionnaire (PHQ-9) depression scale
  2. Conducts initial visit including detailed depression history and education about the nature of depression and the goals and expectations of treatment
  3. Consults with patient and primary care provider about treatment options and preferences; coordinates initiation of treatment plan
  4. Monitors patient closely (in-person or by phone) for changes in severity of symptoms and medication side effects; educates patients about medications and medication side effects as needed; encourages treatment adherence
  5. Uses behavioral activation techniques with patients as an adjunct to other treatments
  6. Provides optional evidence-based, brief structures psychotherapy
  7. Participates in regular caseload supervision with psychiatrist, focusing on patients not adequately improved within specified timeframe (e.g., less than 50% reduction in symptoms after 8-12 weeks in treatment)
  8. Coordinates and facilitates communication between patient, primary care physician and consulting psychiatrist; provides recommendations for change in treatment plan according to evidence-based algorithm and expert supervision; supports implementation of new plan
  9. Documents all encounters according to organizational policies and procedures; monitors outcome measurements
  10. Facilitates treatment referrals, as needed
  11. Completes relapse prevention plan with patients who are in remission


Degree in nursing, social work, marriage and family therapy or psychology.  Effective written and verbal communication skills.  Demonstrated ability to establish rapport quickly with a wide range of people.  Minimum two years clinical experience in a relevant setting.  Knowledge of community resources.


Experience with depression and depression treatment.  Experience working with medically ill and/or older adults.  Prior exposure to brief, structured counseling techniques.

Project Vida Health Center in El Paso has agreed to share their Care Manager description.  The Wellness Coalition from Montgomery also is allowing us to post their Wellness Case Manager and Wellness Advocate job specifications.  Also included is the “Embedded Integrated Care Coordinator” job description created by the Providence Center in Providence, RI.