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Care Management Plus |
Multistate |
| The Care Management Plus model improves care for complex patients by introducing two key components into patients' care: care teams that include care managers (typically a nurse or social worker) and the effective use of an electronic information technology system. Primary care physicians identify patients with complex needs and refer them to a care manager. The care manager then works with the patient, family members, physicians and other healthcare providers to create a personalized care plan. In addition to ensuring patients' adherence to care plans, care managers educate patients and caregivers on disease management, how to effectively navigate the healthcare system, and provide links to community resources. An electronic information system supports the interdisciplinary care team by incorporating protocols and reminders for optimal patient care. Examples of electronic supports include a Care Management Tracking database and Patient Summary sheets. | |
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Partner Organizations |
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Target Population |
Patients with complex care needs |
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Care Team |
Care manager (social worker or nurse), primary care physicians, specialists |
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Timeframe |
2001 - present |
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Results/ Studies |
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Funding |
Private grant |
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Resources |
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