Care Management

What is Care Management?

A team of nurses, social workers and community health workers who provide extra support to help you stay healthy. (Download the full brochure about Care Management at CHA).

Where Are Care Managers?

At most CHA care centers. Care Managers may speak with you by phone or in person. They may visit you at your home or in the community.

Care Management Services

  • Help navigating the health system
  • Support after you leave the hospital
  • Health education and coaching
  • Symptom management strategies
  • Coordination among your clinical team
  • Connect with community agencies

How Does It Work?

When you enroll, your care manager will talk with you about your hopes and needs.

Together, we will draft a care plan that includes shared goals and action steps that you and your care team may take to help you achieve your goals. The care plan is your plan and can be updated as needed.

  • The program lasts around 3 to 6 months
  • Care management is voluntary
  • You can dis-enroll at any time

Who needs Care Management?

People of All Ages Who:

  • Have a long term (chronic) medical condition that is not getting better
  • Go to the emergency room frequently
  • Have frequent overnight hospital stays
  • Have disabilities or special care needs

More Information About Our Program:

Community Partners

Patients of all ages may require longer-term services to stay healthy – including people with physical, emotional or intellectual challenges, and those with behavioral health or addiction issues. Patients who struggle with mobility as well as those who are blind, deaf or hard-of-hearing may also benefit from these supports.

CHA works closely with community partners who are experts in helping patients with special needs. Patients will receive a care plan that addresses both medical and special care needs.

Long-Term Services and Supports (LTSS CPs)

LTSS Community Partners arrange for specialized services such as personal care attendants, mobility assistance, in-home rehabilitation (physical, speech and/or occupational therapy), day health programs and adult group foster care. Residential, transitional and employment supports may also be available.

Behavioral Health Partnerships (BH CPs)

Behavioral Health Community Partners offer care management that considers your medical care and mental health treatment at CHA and other mental health programs in the community. BH CPs provide healthcare advocacy, medication assistance, residential and day programming, employment support and care transitions assistance for patients who have a persistent mental health diagnosis.

Patient Responsibilities

You are responsible to:

  • Agree to work with a care manager.
  • Give your care manager information to help support your care.
  • Do your best to follow your care plan.
  • Ask questions when you hear or read something you do not understand.
  • Let your care team know if you cannot follow your plan.
  • Tell your care manager or your provider if you no longer want this service.

Patient Rights

You have a right to:

  • Get healthcare information you can understand.
  • Be treated with courtesy and respect inclusive of your cultural, social or religious beliefs.
  • Have full privacy:
    • Your medical and personal data will not be shared unless you agree to it.
    • To know who has access to your data outside CHA
    • To know how CHA protects your privacy, security and confidentiality.
  • Learn about all services available, even those your insurance will not pay for.
  • Know the names of your care manager and other care team members.
  • Talk about all of your options with your provider and have your healthcare choices respected.
  • Have an interpreter at no cost.
  • Leave the program at any time.
  • Request a change in care manager, suggest any changes to the care management program or make a complaint without fear of being punished (call: 617-665-1398).