What is Care Management?

Care management refers to a combination of services and care coordination activities that help patients with chronic or complex conditions manage their health. The ultimate goal of care management is to educate and empower patients to be proactive about healthcare decisions and work with their personalized care team to improve overall health.

Med Net One has a robust care management team. Our multidisciplinary team includes: Registered Nurses, Registered Dietitians, Social Workers, Certified Diabetes Educators, Community Health Workers, Clinical Exercise Specialists, and Certified Lactation Consultants. Our team works in tandem with providers, patients, and caregivers to offer comprehensive, whole-person care. Our care managers provide episodic and longitudinal care management services for moderately complex to high risk patients with the goal of reducing cost, decreasing utilization and improving quality of care, while prioritizing patient experience and satisfaction. In-person visits are held in the comfort of the patient’s doctor’s office. Televisits and telephonic care management support are also offered, allowing patients to connect with their care manager whenever necessary. The care manager works in collaboration and continuous partnership with patients and their families/caregivers, specialty providers, and staff and community resources in a team approach to:

• Promote timely access to appropriate care
• Increase preventive care services
• Reduce emergency room utilization and hospital readmissions
• Increase comprehension through culturally and linguistically appropriate education
• Create and promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregivers
• Improve continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals to increase patient’s ability for self-management and shared decision making
• Provide medication reconciliation
• Connect patients to relevant community resources
• Align resources with patient and population needs
• Assist with advance directives, palliative care, hospice and end of life care coordination
• Engage in quality improvement initiatives

Med Net One participates in Blue Cross Blue Shield of Michigan’s Provider Delivered Care Management (PDCM) Program. For additional information, please visit https://micmt-cares.org/bcbsm-pdcm-program.

Additionally, Med Net One adopts an “all patient, all payer” model of care, providing care management services for patients of other participating health plans.