By Dr. Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN, FCM

Many of you are familiar with my mother’s end-of-life story and the failures in communication that contributed to missed diagnosis opportunities and delayed treatment. It is my belief that if a professional case manager had been embedded within her primary care practice, her journey would have been much different.

To that end, when a friend asked me to mentor him through his DNP journey (he was a nurse practitioner connected with a large primary care practice), I asked him to consider using his practice project to address improving communication and care coordination through the care continuum from acute to community. He agreed and put a dual focus on his project of reducing readmissions and improving 7-day post-discharge follow-up appointment attendance. While using active handover, active patient communication, active care coordination and incorporating telehealth elements, his project accomplished both significant readmission reduction and an enormous increase in 7-day post-discharge follow-up appointment attendance for the project population. This is the value of case management in the primary care space.

This is hardly a surprise to those of us in the professional case management space, yet the embedded professional case manager in the primary care setting is far from commonplace. Another friend was recently referred to a specialist within the same hospital system by her primary care provider. After a workup by the specialist, she received a life-changing diagnosis, started treatments, and attended several appointments with the specialist.  When she attended a follow-up appointment with her primary care physician (PCP), the physician commented that she was “incredibly healthy” and told her she could schedule her next appointment for her annual physical next January.  With my advice, my friend brought all the documentation from the specialist to her appointment. She related to me as she asked, “If I am so darn healthy, why do I have this diagnosis from the specialist you sent me to?” She was met with an embarrassed silence as the PCP reviewed the documents that she provided.

My friend reported that the PCP stated they were mortified that this information had not been relayed to them by the specialist and stated that the connectivity of the electronic medical record was not optimal. The PCP profusely apologized, called the specialist’s office and arranged a call later to discuss co-management of my friend’s care. I can imagine that this happens more frequently than this single episode, and I think of how the presence of a professional case manager could eliminate this communication gap, expedite care coordination, and take the burden of interdisciplinary team communication off the patient or caregiver.

I would love to hear from our community case managers about your experiences and what strategies you use to make the patient experience better. At the upcoming CMSA National Conference, we will have Roundtable Networking, and this important issue is a discussion topic at one of the tables. I invite you to join us, join the conversation, create solutions and disruptively innovate!

Connect with your fellow Case Managers at the 2023 CMSA Annual Conference in Las Vegas, NV. With numerous opportunities to network and connect with your peers, this is a conference not to be missed. Register today at:

Bio: Dr. Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN, FCM, is the Associate Chief Clinical Operations Officer, Care Continuum for University of Illinois Health System, and the current President of the Case Management Society of America National Board of Directors.  She has held positions in acute care as Director of Case Management at several acute care facilities and managed care entities in Illinois, overseeing Utilization Review, Case Management and Social Services for over 14 years; piloting quality improvement initiatives focused on readmission reduction, care coordination through better communication and population health management. Her current passion is around improving health literacy. She is the recipient of the CMSA Foundation Practice Improvement Award (2020) and ANA Illinois Practice Improvement Award (2020) for her work in this area. Dr. Morley also received the AAMCN Managed Care Nurse Leader of the Year in 2010 and the CMSA Fellow of Case Management designation in 2022. Her 1st book, “A Practical Guide to Acute Care Case Management”, published by Blue Bayou Press was released in February 2022. Dr. Morley has over 20 years of nursing experience. Her clinical specialties include Med/Surg, Oncology and Pediatric Nursing. She received her ADN at South Suburban College in South Holland, Il; BSN at Jacksonville University in Jacksonville, FL, MSN from Norwich University in Northfield, VT and her DNP at Chamberlain College of Nursing.