Provides care management and care coordination for adult and pediatric patients with mild to complex illness, in the primary care setting.
Identifies the targeted population and implements clinical interventions and protocols.
Collaborates with PCP, patient and members of health care team including continuum of care settings and community resources.
Provides self-management support and includes patient/family as active members in the team approach.
Facilitate close monitoring of high risk patients to prevent and/or intervene early during acute exacerbations.
Coordinates care between PCP and acute care hospitals, specialists and post -acute care services.