Do case managers (CM) direct the medical care of healthcare providers in primary care settings?

Do Case Managers Direct Medical Care in Primary Care?

No, case managers do not direct the medical care of healthcare providers in primary care settings—medical guidance must always be provided by the patient's primary care physician, nurse practitioner, or physician assistant. 1

The Fundamental Distinction: Coordination vs. Direction

Case managers serve as coordinators and facilitators, not directors of medical decision-making. The American Geriatrics Society explicitly states that while case managers link medical care to broader health support and social services, medical guidance must always remain under the authority of the primary care provider. 1

The hierarchy is clear:

• Primary care providers (physicians, nurse practitioners, physician assistants) retain full authority over medical decisions 1
• Case managers coordinate services, assess needs, and facilitate communication—but do not supersede clinical judgment 1
• Care management assessments and care plans must be available to and approved by the primary care provider 1

What Case Managers Actually Do

Core coordination functions include:

• Conducting comprehensive needs assessments across medical, psychological, functional, and social domains 2
• Developing individualized service plans with active patient and family participation 2
• Linking patients to organizational and community resources, including social services and disease management programs 2
• Maintaining communication and coordination with other providers 1
• Identifying and coordinating access to services such as psychosocial support, substance use treatment, and prevention counseling 1

Case managers facilitate but do not dictate:

• They integrate and coordinate input from multiple specialists when involved in patient care 3
• They facilitate communication between the healthcare team and patients/families to improve coordination of daily care plans 3
• They monitor and evaluate service provision and costs to ensure appropriate resource allocation 2

The Team-Based Model

The American College of Physicians describes three levels of integration, none of which position case managers as directors of medical care: 1

1. Coordinated care: Behavioral and physical health clinicians practice separately with information exchange 1
2. Colocated care: Clinicians deliver care in the same practice with enhanced communication 1
3. Integrated care: Clinicians act together to design a unified patient care plan, but medical decisions remain with licensed providers 1

In HIV care models, the care coordinator (who may be a case manager) is explicitly described as "responsible for maintaining communication and coordination with other providers"—not directing their clinical decisions. 1

Critical Pitfall: Conflict of Interest

A major concern arises when case managers also provide services or work for organizations that provide services. 1 The American Geriatrics Society warns that if the case manager/provider profits from service delivery, services may be provided based on agency profit rather than patient need, or conversely, services may be inappropriately restricted if the manager/provider is at financial risk. 1

The Physician's Essential Role

Physicians and other primary care providers must understand and participate in the care management process, particularly when it determines eligibility for home- and community-based services. 1 The case management team ideally includes a physician, nurse, and/or social worker, but the physician retains medical authority. 1

In effective models, case managers work alongside physicians, nurses, pharmacists, social workers, and other professionals—not above them. 2 They maintain regular office rounds to discuss cases and educate staff about patient risk factors, but clinical decisions remain with licensed providers. 2, 4

Patient-Centered Decision Making

Patients and families must participate actively in formulating individual care plans. 1 Case managers empower patients in determining what services are offered and chosen, but when a particular service is denied, terminated, or restricted, patients must be informed promptly and given the right to appeal. 1