What specifically is a care manager?

A care manager is a member of the practice team who works directly with patients to provide care management. A care manager is usually an experienced nurse, social worker, or other health care professional who coordinates care and handles patient needs.
It may be easier to understand the care manager role by describing common or everyday activities care managers can perform.

A care manager can:

• Develop a plan of care that complements the provider’s plan of care and that addresses physical, educational, and psychosocial needs for the patient/family. Note that plan of care can be an area of misunderstanding. There may be three plans: 1) The medical plan created by the provider, 2) the self-management action plan developed with the patient, and 3) the care management implementation plan which the care manager uses to address barriers, address risk/safety, or marry the medical plan and self-management action plan

• Identify patients needing additional support such as those with chronic conditions needing management or social issues impeding health improvement

• Provide self-management support with a focus on health behavior changes to manage chronic conditions. This usually includes using a motivational interviewing or an empowerment approach with patients

• Provide patient/family education with teach back (teach back is a method used by healthcare providers to confirm whether a patient understands what is being explained)

• Provide resource support, education and care coordination during transitions between health care settings or to home or a facility

• Provide assistance with medication management and reconciliation

• Refer patients to community and social service resources for additional help and support

• Assist with advance directives