The Community Health Team Case Manager promotes the Patient-Centered Care Medical Home by working with all Community Health Team (CHT) members in the coordination of patient care with Blueprint participating primary care practices. Patient care will require visiting patients in multiple settings including the CHT office, in Primary Care office, in patient's home, in-patient and long-term care settings. The CHT Case Manager partners with the physicians and other members of the healthcare delivery team to establish improved coordination of the healthcare delivery system, ensuring that patients and families are involved in chronic disease self-management. The CHT Case Manager is responsible for assisting CHT leadership in the implementation of operations and monitoring of outcomes.
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