Care Transformation

Care Management


What is Care Management?

Care Management is a primary care-based intensive outpatient care program for predicted highest‐cost or at-risk members (patients at high risk or rising risk for poor outcomes at high costs). Care is proactive and guided by an iterative care plan shared with the patient and across the care team. Components of care management are described below:

Care Coordination

The goal of care coordination is wellness and prevention of ill health. This included the interactions and interventions that help ensure a patient’s health care needs and preferences are understood and are shared between providers, patients and families as a patient moves from one health care setting to another. These interventions are provided by a care manager or by a health navigator who may also be able to connect the patient to resources in the community. The care team works with the patient towards meeting the patient and their family’s comprehensive medical, behavioral health and psychosocial needs, while promoting quality and cost-effective outcomes. The care team has regular contact with the patient with frequency determined by the acuity of these needs, and the patient’s level of engagement.

High Risk Care Management

This is a delivery model where a patient is engaged by the care team to participate in their own plan of care for a specific period of time, and to be actively involved in continuing self-management afterwards. This includes a collaborative process of patient assessment, care planning, facilitation, evaluation and advocacy for options and services available to the patient. The HRCM program best serves at-risk patients as indicated by high risk scores, utilization triggers (high or unnecessary emergency room, inpatient and pharmacy utilization), or multiple chronic illnesses or co-morbidities.

Behavioral Health Management

Also known as Complex Care Management, this service is provided to coordinate health care services for patients with various co-morbidities and possible psycho-social issues. These patients require extensive use of resources or need assistance to coordinate their complex care. These services are usually provided by Medical Social Workers (MSW), MAs or Behavioral Health Care Managers with support from a psychiatric provider.

Transitional Care Management

These are Case Management services geared towards meeting the patient’s needs for just one episode of care. This may include outreach by an ambulatory nurse during a patient’s inpatient stay for an acute problem or follow-up afterwards, and supports a primary care team which may not have access to the hospital services. Transitional Care Management (TCM) visits for unplanned medical admissions are also a good time to discuss other types of care management because patient may need some ongoing support.

Chronic Care Management

Also known as Disease Management, this involves specialized follow-up by a multidisciplinary team that assists with the reduction of hospitalizations, ED visits, and exacerbations of the chronic condition(s) and improvements in control of measures of quality for these patients. Care Managers may have access to population health tools and tracking systems that facilitate the care of patients with chronic disease(s).

Care Management Teams across UW Medicine


UW Medical Center

Neighborhood Clinics

Valley Medical Center

Central Team

Population Health Management central Care Management Team (l-r) Medical Director Elizabeth Paesch, Program Managers Erica Strait and Nkem Akinsoto, Director of Patient Outreach & Care Management Tammy Wilson, with the CMS award.

Lexicon of Terms

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