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Care Management

In Primary Care

Care management is a nationally accredited program that gives patients extra support to stay healthy. Our team includes nurses, social workers and community health workers. 

Learn more about our program below, or download our Care Management brochure.

If you think care management might help you or a loved one, please talk with your CHA doctor to see if you qualify. 


More Information About our Program

  • Who Needs Care Management?

    People of all ages who:

    • Have a long term (chronic) health problem that is not getting better
    • Go to the emergency room many times a year
    • Have frequent overnight hospital stays
    • Have a disability or a special care need
  • How Does It Work?

    When you enroll, your care manager will talk with you about your hopes and needs. Together, you will create a care plan with your health goals and action steps to take to help you feel better. This is your plan and can be updated as needed.

    • The program lasts around 3 to 6 months
    • It is a voluntary program
    • You can dis-enroll at any time

    If you think care management may be right for you, please talk with your doctor to see if you qualify.

  • About our Community Partners

    Some people need ongoing support to stay healthy – sometimes for many years. Examples include people with physical, emotional or intellectual challenges, and those with behavioral health or addiction issues. People who struggle with mobility as well as those who are blind, deaf or hard-of-hearing may also benefit from these supports.

    CHA works closely with community partners who are experts in helping patients with special needs. Patients will receive a care plan that addresses both medical and special care needs.

  • About Long-Term Services and Supports (LTSS CPs)

    LTSS Community Partners arrange for specialized services such as personal care attendants, mobility assistance, in-home rehabilitation (physical, speech and/or occupational therapy), day health programs and adult group foster care. Residential, transitional and employment supports may also be available.

  • About our Behavioral Health Partnerships (BH CPs)

    Behavioral Health Community Partners offer care management that considers your medical care and mental health treatment at CHA and other mental health programs in the community. BH CPs provide healthcare advocacy, medication assistance, residential and day programming, employment support and care transitions assistance for patients who have a persistent mental health diagnosis.

  • Patient Responsibilities

    You are responsible to:

    • Agree to work with a care manager.
    • Give your care manager information to help support your care.
    • Do your best to follow your care plan.
    • Ask questions when you hear or read something you do not understand.
    • Let your care team know if you cannot follow your plan.
    • Tell your care manager or your provider if you no longer want this service.
  • Patient Rights

    You have a right to:

    • Get healthcare information you can understand.
    • Be treated with courtesy and respect inclusive of your cultural, social or religious beliefs.
    • Have full privacy:
      • Your medical and personal data will not be shared unless you agree to it.
      • To know who has access to your data outside CHA
      • To know how CHA protects your privacy, security and confidentiality.
    • Learn about all services available, even those your insurance will not pay for.
    • Know the names of your care manager and other care team members.
    • Talk about all of your options with your provider and have your healthcare choices respected.
    • Have an interpreter at no cost.
    • Leave the program at any time.
    • Request a change in care manager, suggest any changes to the care management program or make a complaint without fear of being punished (call: 617-665-1398).

Services We Provide

  • Help navigating the health system
  • Support after you leave the hospital
  • Health education and coaching
  • Symptom management strategies
  • Coordination among your clinical team
  • Connect with community agencies

Our National Accreditation

In 2019, CHA received three-year accreditation in Complex Care Management (CCM) from the National Committee for Quality Assurance (NCQA).

CCM is a key component of CHA’s health care model - offering assessment, planning, coordination, evaluation and advocacy for patients (and their families) who have intricate social and behavioral needs. 

Accreditation for Case Management

“This award validates our efforts to create systems and processes that help our most vulnerable patients achieve and sustain better health,” said Eleni Carr, CHA's Chief Care Integration Officer. “Our providers and staff strive to understand our patients in the context of their daily lives outside of our clinic and hospital walls. The social determinants of health, or the conditions in which people are born, live, learn, work and age greatly impact health outcomes. Earning this accreditation is the result of our talented team of compassionate caregivers and commitment to our diverse patient population.”

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