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Health Aff (Millwood). 2019 Jun;38(6):941-949. doi: 10.1377/hlthaff.2019.00030.

Care Management For Older Adults: The Roles Of Nurses, Social Workers, And Physicians.

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Karen Donelan ( ) is a senior scientist at the Health Policy Research Center at the Mongan Institute, Massachusetts General Hospital, and an associate professor in the Department of Medicine at Harvard Medical School, both in Boston.
Yuchiao Chang is a statistician in the Department of Medicine, Massachusetts General Hospital.
Julie Berrett-Abebe is an adjunct faculty member in the School of Social Work at Simmons University, in Boston.
Joanne Spetz is a professor of economics at the Philip R. Lee Institute for Health Policy Studies and the Health Workforce Research Center on Long-Term Care, both at the University of California San Francisco.
David I. Auerbach is an external adjunct faculty member at the Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University, in Bozeman.
Linda Norman is a professor of nursing and dean of the Vanderbilt University School of Nursing, in Nashville, Tennessee.
Peter I. Buerhaus is a professor and director of the Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University.


Care management programs have become more widely adopted as health systems try to improve the coordination and integration of services across the continuum of care, especially for frail older adults. Several models of care suggest the inclusion of registered nurses (RNs) and social workers to assist in these activities. In a 2018 national survey of 410 clinicians in 363 primary care and geriatrics practices caring for frail older adults, we found that nearly 40 percent of practices had no social workers or RNs. However, when both types of providers did work in a practice, social workers were more likely than RNs to be reported to participate in social needs assessment and RNs more likely than social workers to participate in care coordination. Physicians' involvement in social needs assessment and care coordination declined significantly when social workers, RNs, or both were employed in the practice.


aging; care management; frailty; health workforce


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