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The care management program at Nemours Children's is for pediatric patients up to age 21 who have qualifying multiple or uncontrolled chronic conditions and/or have high-cost/high-utilization ED or admissions.

Care management is a collaborative practice model that involves the patient/family, nurses, social workers and physicians. Care managers partner with home care, insurance providers, caregivers and the community on behalf of our patients and families. Our care management team is made up of registered nurses (RNs) and social workers who help facilitate communication, coordinate resources and referrals, and provide the patient/family tools and guidance to help them achieve optimal health.

Patients are typically in care management anywhere from 60-120 days or more. Once goals are achieved, the patient is discharged back to their practice care coordinator via a solid hand-off for continued follow-up and support as needed.

Our mission is to help the patient/family better understand and manage the disease, stay healthy and reduce avoidable emergency room visits and hospital admissions.

 

Key Components of the Care Management Program

  • Point of contact — Registered nurse and/or social worker to contact for concerns, questions or support.
  • Coordination of services — Care managers will assist with coordinating multiple appointments. They will stay in constant communication to eliminate duplication of services and provide support with a multitude of community resources.
  • Individual care plan — Care managers work with the patient/family and providers around health care needs. They will develop goals with the patient/family that will assist in the self-management of the patient’s condition.

 

The care management program is a free service provided to your eligible patients who are returned to your care once their condition has improved with the help of our specialists. Learn more about our Care Management Program.

Eligibility Requirements for the Care Management Program

  • Patients up to age 21
    • AND
  • On a shared DCHN value contract
  • Children with medical complexities, children with uncontrolled or newly diagnosed diabetes, children with high-risk/uncontrolled asthma

Refer a Patient to Nemours Care Management

 Visit NemoursLink or download the care management program request form.