The Nurse Case Management Team collaborates with primary care practices and our interdisciplinary care management team to provide comprehensive care and coordination for complex patients to reduce care fragmentation and preventable utilization as well as to increase patient knowledge and self-management of disease.


  • Provide support, education and coordination of care during transitions of care
  • Provide Complex Case Management
  • Collaborate with Primary Care Providers to support Disease Management
  • Identify and address barriers to care
  • Evaluate factors that may influence a patients ability to self-manage disease
  • Provide Self-Management education and support
  • Develop personalized care plans and proactively follow patients over time
  • Coordinate care with primary care practices, specialists, hospital teams, and our interdisciplinary care management team of pharmacist and social workers.

How to Transform Health MD has Supported Partner Practices

I am in solo private practice in the Towson area. I have partnered with Transform Health MD CTO and this is my second year in the MDPCP program. In the first year, I chose a 70/30 option with the CTO, hired a lead care manager for the practice, thinking that she would work closely with the practice to assist our patients. Although she worked in clinical nursing for more than 30 years, she did not have much exposure to care management. Our start was challenging for me, as I took on a significant workload to help our manager to connect with patients.

For this second year, I decided to change to a 50/50 option. Transform Health MD assigned us a lead care manager, and we met Ms. Elaine Smith. She took the list of patients, started to call them, got connected with them, found out their specific needs, and mobilized the whole team of resources from Transform Health MD, including the pharmacy and social work team. All I have to do is to give her the patients who I feel need extra assistance with social support, education about compliance, medication, or healthcare literacy, and so on.

The support my patients have received during the pandemic has been outstanding. Mrs. H is a 95 year-old widow and lives alone. She was "watering down the milk" trying to get it to last longer, as she was afraid to go to the grocery store. Elaine called in her team of angels, arranged delivery of groceries, medicine, and set her up for Meals-on-Wheels among other things. Mrs. B. lives in a group home, estranged from family. With her fading memory and mental illness, the social worker did a lot of behind the scene work and assisted her main caregiver to have temporary POA, which required verbal consent and witness under the National Public Health Emergency rule. Mr. R. was recently diagnosed with pancreatic cancer, Elaine made all the arrangements for transportation for his treatment to UMMC. The list goes on and on.

I am surely glad that I chose to partner with Transform Health MD, as with my small practice, very limited resources, even knowing where to ask for help, I cannot imagine how much time and work we would have to do to get them. I am very grateful that I have Transform Health MD on my side to help me care for my patients, addressing the social needs, so I can focus mainly on medical aspects. It takes a village to raise a child, it surely takes a wonderful team to provide high quality of care for our patients.

Dr. Jin Gu
Internal Medicine
Towson, MD


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