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Accordia Health coordinates services for patients with complex medical and behavioral health conditions to help them access needed resources across multiple domains, including medical health care, behavioral healthcare, and social support. The goal of Care Management is to help patients living with chronic illness achieve the health goals they make with members of their Care Team.

Patients enrolled in Care Management are assigned to a Care Manager who links the patient to needed services to improve overall health and well being.

Program Overview

The goal of Care Management is to connect patients to the right care at the right time and ensure that patients have access to necessary medical care, behavioral health care, and social supports. Care Managers follow up with patients with complex care needs to help those patients achieve their health goals.

What Care Managers Do

Care Managers work closely with members of the treatment team to identify potential gaps in care and provide timely follow up. Care Managers might:

  • Work closely with medical team to identify gaps in care
  • Assess social determinants of health
  • Use Motivational Interviewing to engage patients and encourage self-management
  • Develop Care Plans with the medical team to address patients’ unmet needs
  • Conduct telephone reminders prior to specialist appointments, lab work, medical testing, and other recommended procedures
  • Follow-up after specialist appointments, lab work, medical testing, and other recommended procedures
  • Increase compliance with medication by providing reminder calls about prescriptions and refills
  • Provide education about disease management to patients and their caregivers
  • Work with inpatient providers to ensure the primary medical provider has all necessary documentation following inpatient hospitalization
  • Connect patients and their caregivers with community resources, which may include housing, transportation, and other available benefits