An integral piece of caring for the whole patient, as we do here at MCHP, is creating an environment that fosters open communication and collaboration among providers across disciplines and settings. Care management is the glue for our integrated care approach to medicine. It is a team-based, patient-centered plan designed to assist patients and their support systems in managing medical, social, and behavioral conditions more effectively, which can include:

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• Management of rare diseases and high-cost procedures

(e.g., transplant, specialty drugs)

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• High-risk care management

(e.g., high utilizers, high-cost beneficiaries)

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• Chronic care management

(e.g., management of multiple chronic conditions)

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• Management of high-risk social environments

(e.g., adverse childhood events, domestic violence)

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• Development of care management assessments/care plans

(across targeted populations)

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• Development and deployment of prevention and population health programs

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• Coordination of services

(e.g., appointment/wellness reminders, social services coordination/referrals)