The Case Manager

The Secret to Turning a Multidisciplinary Clinic into an Interdisciplinary Clinic

By William Morgan, DC

Managing patients in a multidisciplinary clinic, such as a spine center, is usually done in a somewhat haphazard manner. The patient enters the clinic by referral or through direct access to one of the providers. The provider could be a chiropractor, neurologist, orthopedist, PMR or any number of specialists. This initial provider has first right of refusal regarding whether to treat or refer the patient. When and if the first provider feels it is appropriate to refer a patient to another discipline, he or she will select the next specialty to be tried. This method of case management is really a “daisy chain” of successive treatment trials rather than a thoughtful and deliberate synchronization of care.

This type of management reduces the synergy of being interdisciplinary to merely being multidisciplinary. Simply having a variety of different specialties together does not make a clinic more proficient. An interdisciplinary clinic has an organized method to maximize the effectiveness of treatment using various specialties in concert.  In contrast, a multidisciplinary clinic simply has different disciplines of care available—but no coordinated approach to that care.

The Case Manager 

The case manager helps the referring provider or patient to select the best provider to initiate care, and then follows that patient’s case to completion. The case manager is usually a mid-level provider such as a RN, FNP or PA.  The case manager ensures that appropriate outcome measures are initiated during the preliminary visit and at regular intervals. The results of the outcome measures may be used to modify care. The goal of the case manger should be to reach a point of case completion (see Case Completion, ACA News, May 2005, pg. 10). While the provider works toward case completion, the patient’s care should gradually shift from passive to active care.

The case manager will shepherd the patient through the most conservative care that is appropriate for that patient’s condition. Frequently, the most conservative care for a patient will be chiropractic. However, if a patient presents with something more ominous, such as a conus medularis syndrome, then a neurosurgical consult would be the most conservative care appropriate.  

Creating the Case Manager Position

When creating a case manager position it is important to empower the manager with the tools to operate efficiently, while providing guidelines that are well defined and reflect evidence-based and safety-minded algorithms.

The case manager is tasked with maximizing the use of outcome measures, flow charts, progression from passive to active care, and patient follow-up.  The case manager sends periodic and regular reports to third parties, and facilitates interdisciplinary communication.  The manager should feel comfortable in seeking consultations from various providers, as needed.

Solidifying the Team Approach

Regular meetings with the different clinic specialties and the case manager will ensure that patients receive the most appropriate care and will provide an additional layer of safety and reflection. This will also give the clinic a chance to improve efficiency by coordinating care: graduating from passive care to the active care of rehabilitation and ensuring that ergonomic evaluations, back school, and wellness programs have been implemented.  

The case manager ensures that outcome measures are completed regularly and utilized in decision-making (i.e. deciding if the patient’s condition is permanent and stationary or if the current line of treatment has reached maximum effectiveness and another treatment should be utilized) and that appropriate reports are completed. The case manager will also see that referring providers are kept apprised of the patient’s progress and that third-party payers receive adequate and appropriate clinical appraisals. 

In conclusion, the case manager’s work will ensure that patients receive the most appropriate interdisciplinary care possible until the case is completed.