To provide care planning and care coordination across the continuum for at risk patients though longitudinal care management and target episodic care management.


  • Two Step Risk Stratification: Case Managers work with our data team to stratify patients by risk level using a population health platform that analyzes patient characteristics such as chronic disease, utilization and costs. Case Managers collaborate with primary care providers to add clinical judgment to further adjust the risk level of their patients. This process allows providers and the care management team to predict the likelihood of negative health outcomes and target appropriate outreach and care plan development.
  • Longitudinal Care Management: Lead case managers work as part of the interdisciplinary care team to develop personalized care plans for high-risk, high- need patients and proactively outreach on a regular basis to provide longitudinal, relationship-based care. Patients who can benefit from longitudinal care management include those with complex treatment plans, multiple co-morbidities, high inpatient and emergency room utilization, serious mental illness, and social risk factors. The team works collaboratively with patients and families, primary care providers, hospitals, specialists and community agencies to help coordinate care and services.
  • Episodic Care Management: the team will provide targeted short-term care management as needed. This includes medication reconciliation, resource management, coordination and accurate information sharing during transitions of care (e.g. hospital to home, post-acute care settings), as well as outreach and education for a new diagnosis or injury, and support during an exacerbation or change in stability of chronic conditions.