Care managers work as part of a clinical team to educate and empower patients — often those with chronic
disease — to reach their self-management goals. Care managers may be registered nurses, social workers,
and gerontologists, or have training in other health fields and disciplines. The following are examples of the
services that care managers may provide:
- Coordinate patients' hospital discharge plans
- Support the transition from an acute care setting to the home
- Communicate with patients through visits and phone calls after discharge
- Identify and link patients to appropriate support and services in the community
- Help patients and their families to cope with complicated health issues
RHIhub's Chronic Disease Topic Guide provides information and answers to
frequently asked questions on the rural impact of chronic disease.
Resources to Learn More
Management: Implications for Medical Practice, Health Policy, and Health Services Research
This issue brief describes care management as a population health tool, defines care management, and presents
various strategies and recommendations.
Organization(s): Agency for Healthcare Research and Quality
Management for Medicaid Enrollees through Community Health Teams
An overview of community health team programs in eight states that provide an array of targeted services, from
care coordination to self-management coaching.
Organization(s): The Commonwealth Fund
Author(s): Takach, M. & Buxbaum, J.
Commission for Case Manager
Certification Issue Briefs
The Commission for Case Manager Certification is the first and largest nationally accredited organization that
certifies case managers. This site contains links to issue briefs that CCMC has conducted on the role of case
managers in care coordination.
Organization(s): Commission for Case Manager Certification
the Role of the Embedded Care Manager
This report provides a comprehensive review of incorporating an Embedded Care Manager into a care plan.
Citation: Professional Case Management, 18 (4): 182-187
Author(s): Hines, P. & Mercury, M.