Care Management and Care Coordination in Long-Term Care

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, [email protected]



Erikson, CE, Pittman, P, LaFrance, A, Chapman, SA. Alternative payment models lead to strategic care coordination workforce investments. Nursing Outlook, 2017, 65 (6): 737-745.

Care coordination is generally viewed as a key to success for health systems seeking to adapt to a range of new value-based payment policies. This study explores care coordination staffing in four health systems participating in new payment models, including Medicaid payment reform and Accountable Care Organizations. Comparative case study design is used to describe models of care coordination. Analysis of 43 semi-structured interviews with leadership, clinicians, and care coordination staff at four health systems engaged in value-based contracts. Each of the sites engaged in significant task shifting of low-complexity care coordination activities to licensed practical nurses, medical assistants, and other unlicensed personnel freeing up registered nurses and social workers for more complex patients. Few have care coordination experience, requiring a significant investment in on-the-job training. Payment reform is leading to a greater investment in the care coordination workforce. However, demonstrating the return on investment remains a challenge.