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Home : Primary Care Clinics : Primary Care : Case Management Program

Case Management Program

The Meriter Health Services Case Management Program is a clinic-based initiative to assist Meriter Medical Group (MMG) primary care patients, their families and the MMG physicians and staff, in the planning, coordination and management of care services for those with complex medical, social and/or financial needs.

Our mission as the Care Coordination Department is to coordinate services and resources across the continuum of health care to assist patients in reaching their optimal health.

Support for the patient’s journey is achieved through the development of a plan of care with the participation of all members of the health care team. The focus is on the unique needs and goals of the patient through engagement, shared decision making and collaboration in care.

Success will be achieved through appropriate patient identification, team communication, patient-centered planning and patient monitoring. The patient, family and primary care team will be provided with assistance in navigating the health care system.

Frequently Asked Questions

What is the Case Management Program?
The goal of our program is to work with you and your health care team to:
  • Identify your health care needs and goals, as well as communicate them to your health care team
  • Work with your health care team to make sure they're meeting your needs
  • Assist you in coordinating your health care with primary and specialty care providers, as well as your care within the hospital, clinic and community
  • Help you understand your health problems, treatments and options
  • Facilitate your access to services at Meriter and in the community

Who is eligible for the program?
You must be under the care of a Meriter Medical Group primary care physician, as well as meet some of the program's set criteria, such as having 3 or more illnesses or multiple visits to the Emergency Department and hospital admissions.

What are the benefits of the program?
You'll have a consistent contact person from our program who will help you navigate the health care
system, and hopefully, improve your health and wellbeing. Your case manager will be your health care advocate and make sure you're getting well-coordinated care when you need it. They can also be your link to services at Meriter and throughout the community.

Is there a cost?
No, there is no cost to the program, as it is supported through the Meriter Foundation.

What can I expect if I choose to participate?
You'll be contacted by a case manager who will do an initial assessment with you over the phone. Your case manager will then develop an individualized care plan with goals for you and your family. Your case manager will partner with you, your family and your health care providers to put the plan into action. Your progress will be constantly evaluated, making sure your goals are being met and adjusting the plan if needed. As long as you're working towards your goals, you'll continue to be part of the program. Once you're meeting your goals and your health is on-track, you can discuss transitioning out of the program.

How can I sign up for the program?
Simply contact your primary care physician and he/she will refer you into the program. Your physician will also be happy to answer any of your other questions about the program.