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Pascale Carayon, Ann Schoofs Hundt, Peter Hoonakker, Sarah Kianfar, Bashar Alyousef, Doreen Salek, Randi S Cartmill, James M Walker, Janet Tomcavage


Objectives: The aim of this study is to assess the contributions of care management as perceived by care managers themselves.

Study Design: Focus groups and interviews with care managers who coordinate care for chronic obstructive pulmonary disease and congestive heart failure patients, as well as patients undergoing major surgery.

Methods: We collected data in focus groups and interviews with 12 care managers working in the Keystone Beacon Community project, including 5 care managers working in hospitals, 2 employed in outpatient clinics and 4 telephoning discharged patients from a Transitions of Care (TOC) call center.

Results: Inpatient care managers believe that (1) ensuring primary care provider follow-up, (2) coordinating appropriate services, (3) providing patient education, and (4) ensuring accurate medication reconciliation have the greatest impact on patient clinical outcomes. In contrast, outpatient and TOC care managers believe that (1) teaching patients the signs and symptoms of acute exacerbations and (2) building effective relationships with patients improve patient outcomes most. Some care management activities were perceived to have greater impact on patients with certain conditions (e.g., outpatient and TOC care managers saw effective relationships as having more impact on patients with COPD). All care managers believed that relationships with patients have the greatest impact on patient satisfaction, while the support they provide clinicians has the greatest impact on clinician satisfaction.

Conclusions: These findings may improve best practice for care managers by focusing interventions on the most effective activities for patients with specific medical conditions.


care manager; care coordination; case management; emergency treatment; hospital readmission; patient admission

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