The need for case management is particularly high among elderly patients suffering from isolation, depression, frailty, or chronic or disabling conditions. Patients may lack the social supports or capacity to reach out for help, and family members or other caregivers may lack the resources they need to provide appropriate or adequate care. Given these challenges, the fragmentation of social services in conjunction with medical care can function as an overwhelming barrier to access necessary care to support the “whole patient”. Health center based case management can offer an integrated and holistic approach to patient care that encompasses medical, psycho-social and home.
