Care Management and Care Coordination in Long-Term Care

Team: Susan Chapman (UCSF), Alicia LaFrance, MSW, MPH (UCSF), Clese Erikson, MPAff (GWU), and Patricia Pittman (GWU)


Care management and care coordination is a growing field in long-term care, particularly at the interface of long-term care, acute care, and home care. The questions of how care managers are being used, how they are educated for their work, and how they interact with other members of the health care team are largely unanswered.


Key Questions

  • What are the disciplines represented in care management teams and the role, job titles, and functions of each member of the team?
  • What are the organizational structures, reporting relationships, and communications between care management team members (nurses, physicians, social workers, pharmacists, rehabilitation therapists and non-licensed workers such as medical assistants and community health workers); what are the communication and referrals processes across the delivery system?
  • What are the requirements for outcome measures to assess the effectiveness of care management required by payers?
  • The study was conducted in partnership with George Washington University

For questions, contact: Susan A. Chapman, PhD, RN, FAAN, Co-Director, UCSF Health Workforce Research Center on Long-Term Care,