What is care management?

Care Management Definition

Care management programs apply systems, science, incentives, and information to improve medical practice  and assist consumers and their support system to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively.

The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services.

Care Management Framework:

The following framework (see other side) outlines and defines the key components of a comprehensive care management program and a care management plan and provides examples of tools and strategies that can be used by states in designing programs to effectively meet the needs of beneficiaries with complex and special needs.

 Care Management Components Definition Tools / Strategies 

  • Identification
  • Stratification
  • Prioritization
  • Identification, stratification and prioritization should be used to identify consumers at the highest risk who offer the greatest potential for improvements in health outcomes.
  • Programs should incorporate clinical and non-clinical sources of information to identify consumers who will most benefit from care management.
  •  Health risk assessments
  • ƒ Predictive models (algorithm–driven model that uses multiple  inputs to predict high-risk opportunities for care management)
  • ƒ Surveys (e.g., Patient Health Questionnaire 9, Short Form 12)
  •  ƒCase finding (e.g., chart reviews, surveys)
  • ƒ Referrals (from member, provider, community)
  • Intervention
  • Interventions should be tailored to meet individual consumer need, respecting the role of the consumer to be a decision maker in the care planning process.
  • Interventions should be designed to best serve the consumer, be multi-faceted, improve quality and cost effectiveness, and ensure coordination of care.
  • ƒ Evidence-based practices
  • ƒ Interactive care plan, developed based on consumer-set  priorities
  • ƒ Multidisciplinary care teams
  • ƒ “Go to” person ƒ Medical home
  • ƒ Physical/behavioral health integration
  • ƒ Specialized patient engagement (e.g., self-management training)
  • Evaluation
  • Evaluation should include systematic measurement, testing, and analysis to ensure that tailored interventions improve quality, efficiency, and effectiveness.
  • Careful and consistent evaluation will build the evidence base in terms of what works for complex and special need populations.
  • ƒ Program evaluations
  • ƒ Rapid-cycle micro experiments (e.g., continuous quality  improvement, testing, and program adjustments)
  • ƒ Representative measures of quality (e.g., HEDIS, CAHPS)
  • ƒ Representative measures of cost (e.g., ROI calculations)
  • Payment/Financing
  • Payment/financing should be aligned to support improvements in care management by rewarding consumers and providers for participating in interventions/evaluations and establishing accountability for quality and cost.
  • ƒ Pay for performance at multiple levels (e.g., health plan,  provider, and consumer level)
  •  ƒShare in program savings (gain sharing)
  • ƒ Case management/medical home payments


The Functions of a Care Management Plan include:

  • Access to and systematic use of data to include IC Reports, Provider Portal, Pharmacy Home, CMIS, to target recipients and providers for outreach, education, and intervention
  • Monitoring system access to care, services, and treatment including linkage to medical home
  • Addressing the total individual, inclusive of medical, psycho-social, behavioral, and spiritual needs.
  • Involvement of the recipient and their support systems (i.e. caregiver, family, etc.) in the decision-making process
  • Use of a patient-centric, collaborative partnership approach to assist the recipient with improved self-care
  • Utilization of proven processes to measure a recipient’s understanding and acceptance of the proposed plans, his/her willingness to change, and his/her support to maintain health behavior change
  • Expanding the interdisciplinary team in planning care for individuals 
  • Communicating and coordinating with all providers and members of the care team, in an effort to minimize fragmented care
  • Navigating transitions of care
  • Monitoring quality and effectiveness of interventions to the population by setting both long term and short term specific, measurable goals.
  • Advocating for recipients and supporting providers to ensure delivery of appropriate, evidence based care 
  • Supporting the medical home through education and outreach to recipients & providers
  • Facilitating Quality Improvement activities that educate, support, and monitor providers regarding evidence based care for best practice
  • National Standards of Care (Adapted from CMSA, 2010)


Components of care management

  • Patient identification and comprehensive assessment:
    • Identify patients through direct referrals, by mining administrative claims data (risk stratification tools, frequent hospital and emergency room admissions),
    • through screenings and assessments,
    • and through chart reviews that identify gaps in care.
  • Developing an individualized Care Management Plan:
    • The health care team — including the care manager, primary care provider, patient and family/caregiver — agree on goals in a care plan.
    • Care coordination: The care manager (CM) ensures the patient’s care plan is implemented, communicating and coordinating across providers and delivery settings.
    • Reassessment and monitoring: Monitor the patient’s progress toward goal achievement on an ongoing basis, adjusting care plans as needed.

Care managers are to implement a collaborative process of:

  • assessment
  • planning
  • facilitation
  • coordination of care
  • education
  • advocacy
  • evaluation

The Care Management Plan includes an assessment of the patient’s progress toward overcoming barriers to care and meeting patient centered goals, as well as condition/disease specific outcomes that lead toward enhanced self-management.

The Care Management Plan includes reassessment and adjusting the care plan and its goals on an ongoing basis.

Evaluating the patient’s social needs (e.g., transportation, shelter, food) and personal preferences (e.g., values and areas of interest such as religious affiliations, social and vocational goals) can drive activities, supports and case management services. Understanding these areas can help to create individualized, person-centered case Care Management Plan.

The care management team identifies and addresses all obstacles to a patient receiving or participating in a care management plan.

An analysis of potential barriers can include issues such as language or literacy; lack of or limited access to reliable transportation; a patient’s lack of understanding of a condition; a patient’s lack of motivation; financial or insurance issues; cultural or spiritual beliefs; visual or hearing impairment; and psychological impairment.

Utilize a team approach

Utilization of an interdisciplinary team including network resources, community resources, and the care team at the medical home, especially involvement of the Primary Care Provider (PCP) provides the optimal benefit for the patient. The team will utilize all appropriate staff/ network resources to ensure the care management needs of the patient are met:

  • Primarimages49y Care Managers (RNs, ENs, ENAs)
  • Care Management Support (social workers, LPNs, Behavioral Health Specialists, Palliative Care Coordinators, Dietitians, other clinical professionals)
  • Pharmacist and pharmacy assistants
  • Non-licensed staff to support the care managers in their outreach and education efforts.
  • Non-clinical personnel to provide administrative help (e.g., reminding patients about appointments and ensuring that follow-up visits to specialists are kept).

In addition to the above, each network has a medical director, psychiatrist, and other physician champions/consultants who are available for team conferences and problem solving care plans for difficult to manage patients.

The team at the Medical Home is also a key player on the care management team. Care managers provide timely information to the PCP about the hospitalization, social and environmental concerns about the involvement of other services and providers. They communicate with PCP on patient goals, plans, education, adherence. Care managers also work with clients to prepare them for provider encounters—for example, encouraging them to ask questions when instructions are not clear (and to bring a list of questions to the visit), to gather their medications in advance of the visit, and to bring a personal health record with them.

Care managers sometimes accompany patients to physician visits when such assistance is requested.

Network care managers and QI Teams are also responsible for helping physician practices identify patients with high risk conditions or needs, assisting providers with disease management education and follow-up, helping patients coordinate their care or access needed services, and collecting performance data.

Local, community resources are also an integral part of the care management team approach. Care managers are familiar with local community organizations and state agencies that can help to meet their clients’ needs, and facilitate these connections when appropriate Mental health agencies, faith based organizations, Area Agencies on Aging, disability centers, and other community or regional organizations are often engaged by network staff to provide additional local support to clients as necessary.


  1. Mechanic. Will Care Management Improve the Value of U.S. Health Care? Background Paper for the 11th Annual Princeton Conference.

          Community Care of North Carolina (CCNC)


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