Care Managers work with individuals to identify needs and develop a comprehensive “plan of care” to meet the identified needs. The care manager and individual also develop a “care team” comprised of various medical, behavioral health, and other providers in the community who all come together to support the individual in achieving the defined goals and in obtaining optimal health.
Individuals must be diagnosed with:
two or more chronic conditions (such as substance use disorder, asthma, diabetes) or
a serious mental illness
Individuals must also have significant behavioral, medical, or social risk factors which can be addressed through care management.