10 Characteristics of CDPHP’s Embedded Case Management Model

Following in the footsteps of Geisinger Health System’s embedded case manager model, Capital District Physicians Health Plan (CDPHP’s) Enhanced Primary Care effort used embedded nurse case managers to move from a provider-centered to a patient-centered model. The model helped to reduce hospital readmissions and emergency room (ER) visits and tighten transitions of care for high-risk patients. Here, Charlene Schlude, RN, CCM, CDPHP director of case management, lists the top 10 aspects of the embedded case management model.

  • One registered nurse (RN) covering two Enhanced Primary Care (EPC) practices two times per week.
  • High focus on Medicaid and Medicare patients.
  • Educational materials funded by the health plan.
  • Varied hours, based on practice availability.
  • Face-to face introductions with telephonic follow-up.
  • Direct documentation in electronic medical records (EMR).
  • Focus on self-management, which aligns with Level 3 NCQA requirements.
  • Social work case management as needed.
  • Pharmacy case management consultation.
  • Collaboration with internal quality department for gap closure.

Source: Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination


Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination
examines two promising pilots in embedded case management: Nurse Navigators working alongside physicians in Bon Secours Health System’s Advanced Medical Home program, and Nurse Case Managers at the heart of CDPHP’s Enhanced Primary Care effort.

This entry was posted in affordable care act, Avoidable Hospitalization, Behavioral Health, Case Managers, Clinical Integration and tagged , , . Bookmark the permalink.
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