Embedded Nurse Case Managers In Primary Care: My Experience And Strategies For Success



Integration of nurse case managers in primary care is an increasingly popular population health strategy to improve healthcare quality, reduce healthcare costs and improve the patient experience. Case managers are intuitive thinkers able to assemble information from various sources and quickly see the “big picture.” This type of thinking enhances their ability to connect relationships, develop strategies to solve problems and modify plans as situations evolve and change. Case managers are also analytical thinkers and use data from multiple information sources to identify and prioritize patient care challenges and be deliberate and focused in finding solutions to new and reoccurring problems. Intuitive and analytical thinking, clinical experience and using case management processes and standards of practice make nurse case managers an excellent fit as embedded case managers in primary care.


I have been an embedded case manager in a primary care resident clinic at an academic medical center for approximately 2 years. The clinic has 71 residents who rotate through the clinic and 13 attendings providing resident supervision. The interdisciplinary team includes registered nurses, licensed practical nurses, medical assistants, clinical pharmacists, psychology fellows, social workers, a diabetes educator, an outreach worker, two medical directors, a nurse manager, a clinical coordinator and administrative staff. The clinic provides care to over 1,800 patients. Approximately 62% of the clinic population is Black, 28% white, 10% comprise American Indian-Alaskan, Native Hawaii/Pacific Islander and unknown ethnicities. Hypertension, heart failure, diabetes, CKD and COPD are among the top diagnoses seen in the clinic. Like many primary care clinics, patients often have several co-morbid conditions impacting their health. Limited health and reading literacy and other social determinants of health, including mental health, are additional factors that contribute to a moderate to highly complex patient population in the clinic.


The primary goals for embedded nurse case managers include chronic disease management and avoidance of hospital readmissions. I currently manage about 55 patients in the resident clinic. On a typical day, I begin by reviewing discharge reports, including patients discharged following an ED or inpatient admission. Transition of care (TOC) assessments account for 50% of my workday. On average, I complete TOC assessments on five patients per day. Assessments are comprehensive and focus on reviewing discharge instructions, medication review and management, scheduling follow-up with the primary care and specialty providers and coordinating recommended diagnostic tests and procedures. Screening for social determinants of health is also a component of each assessment. Social determinants that frequently impact the patient’s ability to follow the care plan include access to care, income insecurity, limited reading and health literacy.

Medication management involves resolving medication discrepancies, assisting patients in obtaining medications, teaching patients about each medication’s purpose and how to self-administer medications. Due to income insecurity or payer requirements, a call to the provider may be necessary to communicate that a medication is not covered or unaffordable for the patient. If an alternative medication is not available, I initiate prescription assistance program applications and follow up to help patients obtain prescribed medications. If a patient cannot self-administer medications independently, I engage appropriate family members for assistance. Some patients come into the clinic for assistance with reading prescription labels to fill pill boxes correctly. Medication management also involves following up with patients after a scheduled appointment to review any medication changes. Typically, providers do not have time to follow up with patients to ensure adherence to medication changes. So, this is an essential role of embedded case managers.

It may be necessary to coordinate post-acute care services (i.e., home health, remote patient monitoring) following a hospital discharge. Involvement of post-acute care services requires ongoing follow-up and collaboration to evaluate the care plan’s effectiveness and make revisions as needed. To reduce or prevent hospital readmissions, I follow up with patients or caregivers weekly during the 30-day transition periods to assess the patient’s health status and proactively manage any problems that may negatively impact the care plan. Regular communication with the primary care provider and other team members occurs to ensure that the team has updated information on the patient’s health status. Referrals to psychology, social work and community outreach to address social determinants, advance care planning and mental and behavioral health issues enable me to manage my time efficiently to focus on nursing-related interventions.

I use data to stratify and identify patients with high-risk chronic diseases. When I identify these patients, I contact them to discuss the availability of case management services to improve life quality, prevent hospital admissions and reduce out-of-pocket healthcare costs. If patients consent to services, they are placed in a chronic disease management program. Case management services are available to transitional care patients who cannot independently self-manage or need ongoing supervision and support. Evidence-based care pathways guide nurse case managers in the management of chronic diseases. Guidelines published by the American Diabetes Association, the Global Initiative for Chronic Obstructive Lung Disease and the American College of Cardiology are excellent resources for embedded case managers. Knowledge of clinical guidelines improves assessment skills and increases case manager confidence to request provider modifications of the treatment plan.

My encounters with patients are primarily telephonic. Good communication skills help to establish trust and rapport. In practice, I find that it is more effective to listen to patients first, then clarify what I heard before responding. This practice creates an opportunity for the patient to partner in shared decision-making versus only agreeing with the healthcare professional. When I am in the clinic, I typically schedule visits with patients for chronic disease management. Following a comprehensive assessment, case management interventions include education, goal setting and monitoring. I use motivational interviewing to assess a patient’s readiness for change and to help the patient establish at least one goal in a session to improve disease self-management. Common patient barriers to disease self-management include a lack of knowledge about the disease, its progression, trajectory and complications. The embedded case manager has an essential role in removing barriers to facilitate patient self-management. Using “plain talk,” analogies and metaphors help patients understand complex pathophysiology, gain insight into their illness, and increases self-efficacy. The “garden hose” metaphor is just one example of how to explain the effect of hypertension on the brain and kidneys.

On a typical day in the clinic, I make TOC calls and serve as a resource to the clinic team. I may help a triage nurse problem-solve a complex patient call. A physician might ask me to meet briefly with an uninsured patient during an appointment or ask for advice or assistance with nursing home placement for a patient in the community. While on-site, I make sure that I touch base with triage nurses, rooming staff and other team members to “catch up” or find out what is new in the clinic because personal interest and contact build team relationships. I work with a great team, and I have enjoyed this new experience as an embedded case manager. At a day’s end, I almost always have a sense of satisfaction that I have helped nearly every patient I have touched.

One of my most memorable success stories as an embedded case manager involved explaining the need for insulin to a diabetic patient with a BG over 600 in the clinic who refused to initiate insulin. We discussed how the insulin would bring his diabetes under control and prevent further complications. When I asked him if he was coming back to his appointment a week later, he said he would. He returned to the clinic a week later and administered his first insulin injection. Five months later, his A1C decreased from >14% to 7.2%. Another memorable experience involved working with a patient who had a hypertensive crisis to achieve normal blood pressure. I provided education on home blood pressure monitoring, medication management and a heart-healthy diet, emphasizing sodium restriction, including reading food labels. We met weekly for six weeks. His provider titrated his medications as needed to achieve normotensive blood pressure within six weeks.


A comprehensive implementation plan is critical to ensure the success of embedded case management programs in primary care. Nurse case managers have the experience and skills to improve the patient experience, health outcomes and healthcare utilization. An implementation strategy benefits the case manager, providers, the clinic team and the organization. Implementation strategies to consider include:

  1. Understanding the clinic’s patient profile, including demographics, culture and social determinants, to match the right case manager to the population
  2. Evaluating clinical leadership knowledge of the role of case managers and providing education as appropriate
  3. Outlining in writing the role of the nurse case manager for every team member to prevent role confusion and to utilize the case manager effectively
  4. Setting aside time for the leadership team, clinical team and nurse case manager to meet informally to facilitate the integration of a new service into the team
  5. Integrating population health modules or technologies into the existing EMR to improve the efficiency of documentation and communication to benefit the case manager and the clinical team
  6. Utilizing data analytics to extract and process useable data to identify at-risk populations at the point of care to allow proactive versus reactive case management
  7. Identifying outcome measures to demonstrate and present the added value of case managers to clinic leadership, the clinic team and the case manager
  8. Implementing electronic referrals for case management to increase efficiency and to track referral sources
  9. Orienting the case manager within the clinic setting and including the case manager in email distribution lists
  10. Equipping the case manager with the training and decision-support tools to meet or exceed performance expectations, including identified outcome measures and quality indicators

Case managers have a unique and versatile set of skills that can benefit many care settings. As the U.S. healthcare system transforms, the role of case managers will continue to evolve. Primary care is a great place. The availability of post-acute care services has already changed the healthcare landscape. As accountable care organizations increase and reimbursement models continue to reward performance and quality outcomes, case managers are equipped and prepared to provide high-quality, value-added professional case management service in any setting.

kelva edmunds waller

Kelva Edmunds-Waller, MSN, RN, CCM, has more than 37 years of nursing experience, including more than 20 years in leadership roles. She has clinical experience in acute care, home health, infusion therapy, public health, managed care and long-term acute care. She is currently pursuing a DNP degree at Loyola University New Orleans and will complete the program in the summer of 2021. As president of the Central Virginia Chapter of CMSA, she promotes and advocates professional case management practice.


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