Care Management in the Real World: A Small, Private Practice's Journey


Through the addition of a care management function, practices can help high-risk patients navigate complex conditions and vulnerable care transitions.

Fam Pract Manag. 2021 Mar-Apr;28(2):33-36.

Author disclosures: no relevant financial affiliations disclosed.

Ambulatory care management has been around for decades in various forms with various names, but in recent years, it has evolved into an essential strategy for success in primary care practices, particularly those participating in value-based care arrangements. The reason for the growing interest in care management is its potential to improve the health of a practice's most at-risk patients while reducing costs.

But there are some uncertainties for practices exploring the model. Chief among them are the costs to get started, whether the effort will really increase quality of care and reduce costs, and how long it will take to see results.

This article shares a small, private family medicine practice's experience creating a care management program.


Care management does not have one standardized definition, but it does have common elements across medicine.14 These include coordinating and managing transitions of care (e.g., acute to post-acute care settings or acute to home), assessing and closing care gaps, addressing patient needs, coordinating care among the patient's health care team, and navigating the patient through the complexities inherent in the health care system.

Transitions between settings and providers are times when patients are vulnerable to declining health, and a care management safety net is imperative to identify and mitigate the risk of readmission. Care gaps may be social (e.g., food or housing insecurity or lack of access to health care) or preventive (e.g., missing immunizations or cancer screenings). Patients often need education to increase the knowledge, skills, and abilities that enable them to self-manage their chronic conditions or the symptoms and functional changes associated with them. Coordinating care keeps the health care team on the same page and working in concert with the patient's identified goals. The team's assistance in navigating the complex health care system helps patients avoid getting lost and reduces or eliminates frustration.14

Based on patient-identified gaps or needs, care managers perform activities in disease management, case management, care coordination, care navigation, and social work. Care managers may be certified, licensed, or unlicensed depending on the care gaps or patient needs they will be expected to identify and fill. For example, navigating the health care system does not require a professional license, but teaching patients how to take a medication, when to take it, what side effects to watch for and manage, and what to expect from taking it are functions of licensed nurses.

Acknowledging that there is variation in how care management is defined, the definition used in this article is from the American Academy of Family Physicians (AAFP). It defines care management as “activities performed by


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Dr. Hodge is director of transitions of care for Aledade, which partners with primary care physicians to build and lead accountable care organizations (ACOs)....

Dr. Brull is a family physician and owner of Prairie Star Family Practice in Plainville, Kan. She is also vice president of clinical engagement for Aledade. She serves on the American Academy of Family Physicians Board of Directors.

Author disclosures: no relevant financial affiliations disclosed.


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1. Care management. Centers for Medicare & Medicaid Services. Updated Nov. 20, 2019. Accessed Feb. 9, 2021.

2. Care management: implications for medical practice, health policy, and health services research. Agency for Healthcare Research and Quality. April 2015. Reviewed August 2018. Accessed Feb. 9, 2021.

3. Ahmed OI. Disease management, case management, care management, and care coordination: a framework and a brief manual for care programs and staff. Prof Case Manag. 2016;21(3):137–146.

4. Care management. AAFP. Accessed Feb. 9, 2021.


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