title: Embedded CMs work with high-risk patients.
abstract: Care managers embedded in primary care clinics work with patients with high-risk diagnoses and multiple visits to the emergency department or hospital. Patients are identified though risk assessments, suggestions from inpatient case management, and requests from primary care clinicians. Care managers call patients before their clinic visits, look for gaps in care and find out patients' questions and concerns, sharing the information with the treating clinicians. Care managers follow patients for four weeks after their visit, helping them meet their health care goals and follow their treatment plan.
mesh_terms: D019090:Case Management / Q000458:organization & administration* / Q000592:standards; D003150:Community Health Workers / Q000193:education / Q000458:organization & administration* / Q000592:standards; D003159:Community-Institutional Relations; D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000592:standards; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D015438:Health Behavior; D006297:Health Services Accessibility / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D017146:Models, Organizational; D009519:New York City; D010351:Patient Discharge; D010353:Patient Education as Topic / Q000379:methods / Q000458:organization & administration; D010865:Pilot Projects; D011320:Primary Health Care / Q000458:organization & administration* / Q000592:standards; D011369:Professional-Patient Relations; D018570:Risk Assessment / Q000379:methods; D012648:Self Care; D012944:Social Support; D013997:Time Factors; D000078329:Workforce