Patient Case Management in Community Settings
Patient case management is a structured, client-centered process that integrates risk screening, care planning, care coordination, and advocacy to support individuals navigating complex healthcare and social systems—especially within community health settings.
Powered by SocialRoots.ai, the Pillar’s Case Management feature brings this model to life—designed specifically for nonprofits and community health centers.
Definition & Core Components of Pillar Patient Case Management
Case management follows a structured path :
Referral intake
Assessment of medical and social needs
Care plan creation
Coordination of services
Ongoing monitoring and advocacy
With Pillar’s Care Plan Builder, organizations can easily design customized plans tailored to each client’s clinical and social needs—no need for separate systems.
Why Patient Case Management Matters in Community Health
In community health case management, the work often extends beyond medical tasks :
Addressing Social Determinants of Health (SDOH) like housing, food insecurity, and transportation.
Coordinating care with external community partners, not just within a hospital.
Empowering clients with goal tracking and follow-up interventions.
Using Pillar’s Unified Client Charts, case workers can view and manage medical history, SDOH screenings, referrals, and communications in one centralized place.
Case Management vs. Care Coordination
Both play a critical role in community care, and platforms like Pillar unify the two :
Explore Pillar’s Integrated SDOH Workflows that automate both case documentation and coordination across organizations—closing the loop faster.
Role of the Case Manager
In community settings, case managers often wear many hats :
Pillar’s Closed-Loop Referral Engine ensures every referral is tracked, acknowledged, and completed—so case managers spend less time chasing follow-ups.
Common Models of Community Patient Case Management
| Model Type | Key Feature |
|---|---|
| Brokerage | Refers client to appropriate agencies |
| Strengths-Based | Builds on individual capacities |
| Clinical | Overseen by healthcare professionals |
| Custom Reporting & Dashboards | Monitor impact, outcomes, and grant metrics |
| Integrated / Guided Care | Combines primary care with community casework |
Pillar supports multimodal workflows, enabling nonprofits to adapt their preferred model via form customization and dynamic task flows.
Use Custom Forms and Intakes in Pillar to launch programs like mental health support, housing assistance, or chronic disease tracking.
With Real-Time Dashboards, Pillar gives project managers instant visibility into caseload status, outcomes, and impact metrics for funding and compliance.
Technology That Enables It All
Modern patient case management depends on software that’s :
Pillar delivers all of this in a Community-Aligned Case Management System—purpose-built for CHCs, nonprofits, and SDOH programs.
Frequently Asked Questions (FAQ)
Patient case management is a structured process that helps community-based organizations support individuals with complex medical and social needs through assessment, care planning, referrals, and follow-ups.
Care coordination involves aligning services across multiple providers, while case management is a cyclical, personalized approach that includes planning, advocacy, and outcome monitoring.
Community health centers, nonprofits, case workers, and patients with chronic conditions or social barriers benefit from coordinated and personalized support.
Key features include unified patient charts, referral tracking, SDOH screening tools, real-time dashboards, and care plan builders—all available in Pillar by SocialRoots.ai
Ready to Transform How Your Team Manages Patient Cases?
Pillar by SocialRoots.ai gives your organization :
Unified charts
Integrated referrals
Custom workflows
Reporting built for community care
Request a Demo of Pillar and see how we help nonprofits and health centers close care gaps with smart, human-first technology.
