Case management in community nursing: finding, coordinating and following up high-need people
- Safe practice
Case management gives people with complex, long-term needs one nurse who assesses, plans, coordinates services and keeps following them up.
What it is
Case management is a way of organising care for people with high-intensity needs, such as those with several chronic conditions, frailty or social vulnerability, and for their caregivers. It is a collaborative process between the person and the case manager, who agree on goals and work towards them to prevent or delay complications and increase the person's autonomy. The case management nurse assesses the person and their social context, builds an individual plan, links primary care, social and hospital services and follows up proactively by phone, email or home visits. Reviews report better quality of life and self-management and fewer admissions in several studies, but the certainty of the evidence varies.
What it requires
- A clear way to identify who needs case management (registers, family characterisation, hospital discharges).
- Ongoing contact by phone, email and home visits that the person and the family know how to use.
- Agreement with the other services: primary care, specialists, social services and the EPS.
- Resource stewardship: using the right level of care and avoiding unnecessary referrals.
How it is applied (and why)
- Identify people with high-intensity needs from registers, visits and discharges — resources go to those who need them most.
- Assess the person, the caregiver, the home and the social context — needs outside the clinic often block the plan.
- Agree goals with the person and the family — shared goals increase autonomy and adherence.
- Write an individual plan with actions, owners and dates — everyone knows what comes next.
- Coordinate primary care, specialist, social and hospital services — care stays continuous between levels.
- Teach self-management and review the medicines with the team per protocol — the person handles daily care safely.
- Support the caregiver with information and practical help — caregiver strain breaks the plan.
- Follow up proactively by phone, message or home visit, especially after discharge — problems are caught before admission.
- Re-evaluate goals regularly and adjust or close the case — the plan follows the person's changes.
In nursing practice
- In a basic health team, case management builds on the family characterisation and the PICP.
- Use motivational interviewing and reminders to support treatment adherence.
- Check after every discharge that the person has appointments, medicines and clear warning signs.
- Ask early for social help when housing, food or transport put the plan at risk.
Common mistakes
- Choosing people by diagnosis only and ignoring social vulnerability.
- Writing the plan for the person instead of with the person.
- Coordinating by phone without recording agreements.
- Losing contact after discharge, the moment of highest risk.
Test yourself
Think of the answer, then tap the question to see it.
Who benefits most from case management in community nursing?
People with high-intensity needs: several chronic conditions, high vulnerability or frequent admissions, together with their caregivers.
Why are goals agreed with the person in case management?
Because it is a collaborative process that seeks to prevent complications and increase the person's autonomy in decisions.
What follow-up methods does the case manager use?
Phone calls, messages or email, reminders and home visits, especially after hospital discharge.
What did reviews find about case management and blood pressure control?
Short-term reductions in some trials, but no consistent effect and low or very low certainty of evidence.
Elsewhere in DurgiPedia
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Primary Healthcare Case Management Nurses and Assistance Provided to Chronic Patients: A Narrative Review (Molina-Gil MJ, Guerra-Martín MD, De Diego-Cordero R) (Healthcare (PubMed Central), 2024); Effectiveness of nursing case management versus usual care for blood pressure control in adults with hypertension: a systematic review (Mantovani MF et al.) (Investigación y Educación en Enfermería (PubMed Central), 2021); Nursing Management and Professional Concepts, 8.6 Resource Stewardship and Case Management (Open RN, CC BY 4.0) (Open Resources for Nursing (Open RN) / LibreTexts, 2022); Lineamientos para la organización y operación de los Equipos Básicos de Salud (Resolución 2788 de 2022): plan integral de cuidado primario y seguimiento (Ministerio de Salud y Protección Social, Colombia, 2023).
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Representative model, for educational purposes only.