RN Complex Care Manager (per 2,000 attributed lives) to coordinate episodic and longitudinal care management for rising- and high-risk patients, including:

  • Identifying high-risk patients based on risk stratification and PCP referral
  • Assessing the healthcare, educational and psychological needs of the patient/family
  • Collaborating with PCP and other care team members to develop and monitor comprehensive individualized plans of care
  • Providing patient education and self-management support
  • Providing follow-up when patient transitions from one setting to another
  • Uploading care alerts and care plans into CRISP
  • Access to interdisciplinary team for consults on complex patient cases (e.g., pharmacy, dietician, social work, diabetes educator, respiratory therapy)


Pharmacist to conduct comprehensive medication management for rising- and high-risk patients, including:

  • Assessing the patient’s medication therapy
  • Developing and initiating an action plan to address risks and offer potential alternatives

Community Health Worker to provide support to rising- and high-risk patients, including:

  • Assisting with patient activation and self-management support outside of the clinic
  • Managing community-based social service referrals and follow-up

*If care management services are provided by the practice, fee sharing with the CTO will be reduced to 30% for Track 1 and Track 2 practices or 24% for Track 3. 

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