Why Case Management Is Infrastructure, Not Just a Service

Infrastructure is usually something we notice only when it stops working. We rarely think about the electrical grid when the lights turn on. We do not study the plumbing every time water comes from the faucet. Roads, networks, communication systems, and supply chains often become most visible when something breaks between one point and another. Healthcare has connective infrastructure too.

Someone has to understand what a person needs. Someone has to translate those needs into a plan. Someone has to identify the appropriate resources, make the connection, and determine whether that connection actually happened. And when circumstances change, someone or something has to recognize the change and adjust the plan.

In Medicaid, these responsibilities are not merely philosophical ideas. Federal regulations define case management services as assistance that helps eligible individuals gain access to needed medical, social, educational, and other services. The regulation identifies comprehensive assessment, development and periodic revision of a care plan, referrals and related activities, and monitoring and follow up among the functions of case management.

Assessment. Planning. Connection. Monitoring. Feedback. Individually, these are case management activities. Collectively, they resemble the basic functions of a coordination system. That does not mean case management is the entire healthcare infrastructure. It is not. Nor does it mean that every case management program produces the same results.

Research on case management gives us good reason to avoid sweeping conclusions. A systematic review of reviews by Jee Young Joo and Diane Huber examined case management interventions for chronic illnesses and healthcare utilization. The authors found evidence of reductions in healthcare utilization across some outcomes, but the results across the seven systematic reviews they examined were mixed. That distinction matters. If the lesson were simply “case management works,” the solution would be easy. Hire more case managers. But healthcare is rarely that simple.

A highly capable case manager operating inside a poorly connected system may spend enormous amounts of time searching for information, leaving messages, checking portals, repeating documentation, confirming authorizations, locating providers, tracking referrals, and determining whether something that was supposed to happen actually happened. The work is valuable. The friction surrounding the work is not. And that is where the infrastructure question becomes more interesting.

How much of a professional’s time should be spent finding information that already exists somewhere else? Why should a family have to explain the same situation repeatedly to organizations participating in the same person’s care? Why can an authorization exist without the next responsible organization knowing that action is required? Why can a referral be sent without anyone knowing whether the patient ever received the service? Why do changes in eligibility, medications, functional status, housing, transportation, caregiver availability, or family circumstances so often remain isolated inside separate workflows? Those are not simply questions about whether individual professionals care enough. They are questions about system design.

And healthcare policy is increasingly recognizing the importance of these connective functions. Medicaid Health Home services include comprehensive care management, care coordination, comprehensive transitional care and follow up, patient and family support, and referrals to community and social support services. Medicare has moved further in this direction as well. For calendar year 2024, the Centers for Medicare & Medicaid Services finalized separate payment for services including Community Health Integration and Principal Illness Navigation. CMS describes these services as involving activities that can include care coordination, health system navigation, building patient self advocacy skills, and facilitating access to community based social services.

The terminology changes depending on the setting — case manager, care coordinator, navigator, community health worker, transition specialist, social worker, nurse, family caregiver. Those titles should not be treated as interchangeable. Their qualifications, responsibilities, regulations, and scopes of practice can differ significantly. But from a system perspective, many of these people encounter variations of the same fundamental problem: how do we keep a human being from becoming lost between disconnected pieces of healthcare?

Technology should eventually make much of this work easier. But technology alone cannot be the answer. A dashboard that displays fragmented information more beautifully is still displaying fragmented information. A notification that nobody owns does not create accountability. A referral platform that records that something was sent does not tell us whether the person actually received care.

Artificial intelligence may help identify risks, organize information, reduce repetitive administrative work, and recognize patterns across large amounts of data. But a more intelligent tool placed on top of a poorly designed workflow can simply help a dysfunctional process move faster.

The deeper opportunity is to design healthcare around continuity. That means knowing who is responsible for the next action. It means creating better information flow between organizations. It means knowing whether referrals actually close. It means recognizing when approved services do not begin. It means seeing when an authorization is approaching expiration before care is interrupted. It means making important changes in a patient’s circumstances visible to the people who need to respond. And it means preserving enough human judgment to recognize that a patient’s life cannot always be reduced to a status field.

This is one reason case management is such an important place for us to learn. At 1st Acuvenas, we do not see case management as the boundary of the problem. We see it as one of the places where the architecture of healthcare becomes visible. When you stay close enough to the frontline, patterns begin to emerge.

The missed referral is no longer only a missed referral. The expired authorization is no longer only an administrative mistake. The family that does not know who to call is no longer simply an education problem. Repeated often enough, these experiences become signals. They show us where information is not moving, where accountability is unclear, where technology is disconnected from workflow, where organizations operate beside one another instead of with one another, where public programs and private healthcare do not connect cleanly, and where professionals are being asked to compensate manually for weaknesses in the systems surrounding them.

That is the larger lesson. The future of case management should not be limited to asking case managers to work harder. It should include building better infrastructure around the people already doing the work. The strongest healthcare systems will not simply provide excellent individual services. They will become better at connecting them.

Because patients do not experience healthcare as departments, reimbursement codes, portals, contracts, or organizational charts. They experience a journey. And someone still has to make sure that journey makes sense. That is why we believe some of the most important lessons about the future of healthcare can be found remarkably close to the frontline.

From Frontline Insight to Healthcare Infrastructure. That is the conversation we believe is worth continuing.