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Case Manager vs. Care Manager: Differences & Benefits

Case managers and care managers help overwhelmed patients and overburdened practices achieve optimal healthcare outcomes and promote improved quality of life. While fundamentally aligned in their goals, a care manager and a case manager function as two distinct yet integral parts of patient-centered healthcare.

Case management usually focuses on patients with acute conditions who become high utilizers of healthcare services like hospitalizations and emergency department care. 

Data demonstrates that despite only making up 5% of Medicare recipients, patients with acute conditions represent 15% of all hospital stays, 17% of all days spent in the hospital, and 43% of all hospital readmissions. They also have 15% higher hospital bills. These “super utilizer” patients are often helped by intervention from a licensed healthcare professional acting as an individual case manager, who can help coordinate their care and aim to reduce their overall utilization. 

Care management focuses on preventative care, aiming to reduce resource utilization by encouraging patients to proactively engage with their healthcare and the management of their conditions. 

Care management is closely tied to Chronic Care Management (CCM), a service offered through Medicare to any patient with multiple chronic conditions, including diabetes, asthma, and COPD. CCM covers a wider array of Medicare patients than case management does, with around 70% of all enrollees eligible for care management services.

In this article, we will further break down the functions of case management and care management and help you determine whether your practice can benefit from implementing care managers and care management programs.

What is care management?

Care management is a broad healthcare strategy emphasizing collaborative, high-quality, preventative care. Care management delivers accessible, affordable, and individualized care to patients as they navigate complex healthcare systems and manage their chronic illnesses. 

Care management programs strive to eliminate outstanding gaps in care, improve care coordination across healthcare networks and providers, and support ongoing patient education and engagement. These programs also seek to implement healthy lifestyle changes, like improved nutrition, exercise, and socialization, and to ensure all patients have access to reliable transportation to appointments, medication fulfillment and delivery assistance, and local resources to assist with potential financial hardships. 

In addition to the physical aspects of a patient’s health, care management focuses on the patient’s social, psychological, and behavioral needs that contribute to their overall well-being and quality of life. Care management further emphasizes the role of community in an individual’s health. Services seek to include patients, their providers, specialists, mental health professionals, family members, caretakers, and a broader social network in healthcare decisions and illness management. 

Care management for chronic conditions

Care management is heavily associated with Chronic Care Management (CCM), a program launched by the Centers for Medicare & Medicaid Services (CMS) in 2015 to improve care coordination for Medicare patients, drive down escalating healthcare costs, and encourage investment in value-based care initiatives. CCM programs provide patients with dedicated attention from care managers to help achieve these goals. 

Through CCM services, enrolled Medicare patients receive monthly calls from a care manager with complete access to their medical history. This consistent communication cadence allows care managers to guide chronically ill patients through their healthcare journey. Regular conversations enable care managers to discuss self-management techniques, medications and side effects, new and worsening conditions, feelings of anxiety or depression, and other information pertinent to each individual’s health. 

This level of detailed engagement encourages patients to enact healthy lifestyle choices between clinical visits and seek out recommended preventative screenings, vaccinations, and tests, thus preventing care gaps from emerging. 

Learn more: A Guide to Chronic Care Management for Providers

What is a care manager?

A care manager collaborates with patients and providers to evaluate each patient’s unique healthcare journey, provide streamlined access to healthcare resources, and promote high-quality, comprehensive care between clinical visits. The primary focus of a care manager is to provide patients with preventative care.  

Fundamentally, a care manager is an advocate for a patient’s wellness, physically, socially, and mentally. They collaborate with patients on their  health goals and personalized wellness plans. Care managers do not prescribe medication or make diagnoses. Instead, they gather and collate information from patients and their providers, simplify continuity of care and care coordination, and aim to alleviate stress, fear, and other points of distress that could damage patient health. 

Care managers are also trained to address a patient’s Social Determinants of Health (SDOHs). Economic instability, substandard housing accommodations, food deserts, inadequate rural healthcare resources, neighborhood crime, and patient loneliness are just a few of the social conditions that play a dramatic role in a patient’s ability to manage illnesses effectively. These barriers to access can be daunting for patients to face alone. 

However, when partnered with a care manager, patients have access to an advocate who can assist them in obtaining transportation, financial assistance, and community resources. As care managers continue to engage patients and educate them on their conditions, they also empower patients to feel greater confidence and take on a more proactive and preventative role in managing their conditions.  

Learn more: What is a Care Manager? 

What are the responsibilities of a care manager?    

• Connect with patients on their care plans between clinical visits
• Establish strong communication and build meaningful relationships with individual patients
• Coordinate appointments, vaccinations, and screenings with patients and providers
• Assist in medication management, refills, and delivery
• Arrange for transportation to medical appointments if needed
• Advocate for patients and assist them in navigating complex healthcare systems 
• Educate patients on their conditions and provide them with self-management tools and resources to alleviate discomfort and stress 
• Review symptoms, medications, and any new or developing physical concerns
• Discuss SDOHs with patients and provide resources for people with struggles like food insecurity and financial hardship
• Connect patients  to resources to help manage loneliness, anxiety, and depression as needed
• Maintain records of monthly patient progress, risk factors, and other health-related developments
• Manage administrative details like record-keeping
• Address patient questions about their care plan, medications, or chronic conditions 
• Promote improved quality of life and quality of care for patients  

What is case management?

Case management is a specialized healthcare process that strives to provide optimal health outcomes for patients with complex medical conditions. Case management creates dynamic patient solutions through assessment, patient monitoring, wellness planning, care coordination and rehabilitation services, in the hopes of reducing hospital readmittance and emergency service utilization. 

Like care management, case management aims to improve patients’ clinical outcomes, maximize quality of life, and mitigate discomfort. It, too, emphasizes addressing social, behavioral, and mental health in addition to a patient’s physical well-being. 

A focus on patients with acute conditions, debilitating illnesses, and a history of high resource utilization differentiates case management from care management. Case management focuses on a high-risk subset of the population and is usually initiated by a third party, like a health insurance company or healthcare provider.

Case management covers a broader spectrum of services than care management but serves a smaller pool of patients. Case managers are involved with a patient’s providers and specialists, transitional care managers, health insurance providers, legal entities, rehabilitation facilitators, and other relevant parties. Often, patients requiring case management services have a large volume of time-intensive healthcare needs, necessitating the services of a dedicated facilitator like a case manager. 

What is a case manager?

A case manager is typically a licensed Certified Case Manager with educational and professional backgrounds in healthcare, nursing, or social work. Case managers are usually employed by a stakeholder, such as a provider, payer, or government-run entity like Medicaid. This means case managers also have experience handling legal, financial, and medical details pertaining to their stakeholders.

Case managers focus on acute illness and the prevention of further disease progression. They are usually employed after a patient’s illness causes high resource utilization and repeat hospitalizations and severely harms a patient’s quality of life. 

Case managers monitor and manage the patient, their illness, and the use of resources to transition the patient to a stable and comfortable state. Case managers can also be brought into non-acute settings that focus on high-risk diseases (like diabetes or coronary artery disease) to help mitigate conditions before they progress into more problematic stages of illness.  

Case managers usually obtain a degree of accreditation. For example, organizations such as the Commission for Case Manager Certification (CCMC) in the United States offer the Certified Case Manager (CCM) credential. This certification is not a requirement for all case management positions but is often preferred by employers. In some areas, there may also be state-specific regulations or licensure requirements for case managers. Professionals must be aware of and comply with any regional regulations that apply to their practice.

Learn more: Challenges in Delivering High-Quality Care to Patients with Chronic Conditions

What are the responsibilities of a case manager?

The responsibilities of a case manager will differ broadly based on the specifics of each patient’s medical history and healthcare needs. Generally speaking, a case manager should: 

• Monitor patient progress through the collection of vital signs and biometrics
• Evaluate an individual client’s care needs and plan and execute corresponding, comprehensive care plans 
• Reduce hospital readmissions, nonessential resource utilization, and healthcare costs through deliberate intervention and thoughtful care planning
• Facilitate care coordination across multiple providers, specialists, and healthcare networks 
• Assist patients with navigating health insurance, Medicare, and legal processes
• Provide the patient with financial advice and resources 

Care management vs. case management

While these two healthcare concepts share many of the same long-term goals, each approach has essential operational distinctions.

1. Patient eligibility: Care management services offered through a CCM provider are available to any Medicare-enrolled patient with two or more documented chronic conditions who have seen a healthcare provider in the past year. Eligible patients must consent to enroll in a CCM program and receive monthly assistance from care managers.

Case management eligibility is far more complex. It’s initiated by third-party stakeholders rather than a patient and their provider. Case management eligibility is determined by a patient’s healthcare needs, financial and legal issues, resource utilization, and other relevant factors determined by healthcare providers, insurance companies, and state departments. Case managers are often assigned to patients rather than patients electing to participate in the service. 

2. Strategic focus: Care management focuses on preventive care–offering accessible services to maintain a patient’s current level of health and prevent it from declining further. Care management provides services to many patients to help them manage their conditions and maintain their health by engaging with professionals who assist with preventative care, care coordination, and resources like community involvement and transportation services.

Case management focuses on managing acute episodes of a specific disease to prevent it from progressing. Case management serves a population often dealing with more complex, critical illnesses. 

3. Services offered: Chronic Care Management’s care manager services are telephonic/virtual services. Common CCM activities include helping with medication adherence, transportation assistance, SDoH interventions, and preventative assessments.

Case management typically requires monitoring vital signs or other assessments of a clinical condition. Case managers often handle additional complex tasks based on the demands presented by individual patients’ case details.

4. Professional background: Care management can be performed by various individuals, including professional administrative staff, nurses, clinical health coaches, and licensed providers. Many CCM companies provide practices with expertly trained care manager teams, so practices do not have to lean on in-house resources. 

Multidisciplinary Acute Case Management teams are typically led by licensed Certified Case Managers who have social work or nursing backgrounds. 

5. Financial outcomes: CMS reimburses providers to deploy a CCM program. The reimbursement runs an average of $65 per patient monthly for traditional practices and $81 per patient monthly for FQHC and RHC practices*. 

Case Management does not offer a reimbursement per patient. However, it significantly enhances claims management by ensuring that all details of a hospital stay are medically necessary and delivered appropriately. This helps save the hospital and the patient thousands. Although there are differences between the two, both programs are proven to reduce overall healthcare costs by improving patient outcomes and avoiding hospital readmissions.

*Results may vary by provider.

Care coordination vs. case management

Care coordination is a component of case management and care management. Care coordination has a narrower focus on organizing, coordinating, and communicating healthcare services for patients and ensuring continuity of care throughout the transition. Case management and care management encompass care coordination but involves a more comprehensive and holistic approach to managing a patient’s overall care. Properly coordinated care is integral to successful case management and care management programs. 

Implement effective care management through ChartSpan’s turnkey CCM program

ChartSpan’s CCM services include access to a compassionate and knowledgeable care management team ready to guide your patients through the complexities of the healthcare system and toward optimal clinical outcomes. Through ChartSpan’s CCM program, you do not need to worry about hiring and training care managers in-house to support your care management endeavors. We proudly employ a highly skilled team of experienced professionals ready to assist your patients toward brighter healthcare futures.  

With ChartSpan’s CCM services, all enrolled patients receive monthly check-in calls with care managers. Our care managers are intimately acquainted with a patient’s medical history and wellness plans, medications, and potential gaps in care. They are equipped with resources to help them identify problematic signals, like deteriorating symptoms, signs of patient depression, or indicators of financial or social struggles interfering with a patient’s ability to receive care. 

Through ChartSpan’s CCM care managers, the risk of patients slipping through the cracks between clinical visits is significantly reduced. The regular cadence of contact fosters elevated patient engagement with their health journeys. Furthermore, it strengthens the bonds of trust between patients and healthcare providers.  

Our care managers can improve your clinical outcomes by ensuring that patients adhere to their medications each month and never miss screenings due to a lack of transportation, in addition to providing a wide array of other social services. 

Contact us to learn more about our top-tier, turnkey CCM program and how ChartSpan’s care managers can bolster patient trust and elevate the quality of care your practice provides. 

You may also like: 

• The Chronic Care Model Explained
• 11 Features of the Best CCM Companies
• 10 Myths About Running a CCM Program