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Care Management

The Physician Health Partners (PHP) Care Management Department offers a variety of services to our primary care clients.  The care management approach is through a multidisciplinary team made up of nurses, social workers, triage coordinators and census coordinators.  Each practice has an outpatient care manager assigned as their single point of contact for all care management needs or to answer questions. The Care Management team's focus is on the patient to make sure they have the resources and education to get healthy and stay healthy. 

The Care Management Department works together with the physicians, patients and families to:

  • Support efforts in transitions between settings – home, acute care, skilled nursing facilities, home health care and doctor visits
  • Coach patients and family members utilizing a systematic approach that promotes knowledge and self management skills
  • Provide education on available community resources and assistance programs

The Care Management Program includes the following initiatives:

  • Direct Admit to Skilled Nursing Facilities
  • Facility Management
  • Complex Case Management
  • Transitions of Care Program
  • Hip/Knee Replacement Program
  • Situational Case Management

How Are Patients Referred to Care Management?

Each practice can refer their patients to a care manager.  AARP Medicare Complete (Medicare Advantage from United Health) and Medicare fee-for-service (ACO) members can also self-refer themselves to the Care Management Program.