Care Management / Patient Navigation

Care Management is an emerging concept that refers to a set of evidence-based, integrated clinical care activities that are tailored to the individual patient, and that ensure each patient has his or her own coordinated plan of care and services.

The care plan, which is developed collaboratively by the patient and care providers, is designed and implemented to optimize the patient’s health status and quality of life.

The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services.

Patient navigators do just what their title suggests: they help patients navigate the healthcare maze.

Patient Navigators at CMG make sure that patients understand their discharge reports after leaving the hospital, are taking the proper medications, and check in with their physicians for follow-up. Via motivational interview techniques and teach-back, they identify and address barriers to optimal care and wellbeing.

We have seen that these patients are less likely to be readmitted to the hospital, and more likely to be connected in a meaningful way with the physicians who have been following them.

In addition, our team works with high utilizers of the Emergency Department, distinguishing “true” emergencies from preventable ED use and steering those patients with preventable visits toward regular visits with the physicians who can help them. We also strive to help our providers to close gaps in healthcare, identifying high risk patients who have missed regular treatment such as flu shots or testing such as cholesterol or blood sugar screening.

CMG’s navigators are non-clinical. They do not practice any form of medicine; they simply help patients to negotiate the healthcare system. This work helps to ease the burden on providers and their staff, at no additional cost to patients.