Care Management

Chronic conditions account for 90% of the nation's $5.3 trillion in annual healthcare spending (CDC, 2026) — and the members driving that cost are often the ones falling through the cracks between office visits.

Care management is the coordinated set of activities your health plan or provider organization uses to support patients with chronic or complex conditions in those critical gaps between clinical encounters.

What Is Care Management?

Care management is a structured program that coordinates outreach, education, and monitoring for members living with chronic or complex conditions — diabetes, heart disease, Chronic Obstructive Pulmonary Disease (COPD), behavioral health comorbidities — during the periods when they're not sitting in front of a clinician.

In practice, a care manager (typically a nurse or social worker) checks in with members on a regular cadence, tracks adherence to a personalized care plan, coordinates across specialists, and catches deterioration before it turns into an emergency department visit.

One distinction worth drawing clearly: care management and utilization management serve different functions. Care management asks, what does this patient need to do well? Utilization management asks, should this service be approved, and under what conditions? One is proactive support. The other is review and authorization.

Why It Matters to Your Bottom Line

Members with unmanaged chronic disease disproportionately generate the avoidable hospitalizations and emergency visits that erode your medical loss ratio. Effective care management is one of the few interventions that improves member outcomes and plan economics at the same time — rather than forcing a trade-off between the two.

That concentration of spend is exactly why care management sits at the center of value-based contracts. When your plan and providers share incentives for lower total cost and better outcomes, managing rising-risk members between visits becomes a shared operating priority — not a nice-to-have.

How It Works

Effective care management programs follow a consistent operating rhythm:

• Identify and stratify. Members surface through claims data, risk scores, or referral. Risk stratification prioritizes the highest-need cases so your resources go where they'll make the biggest difference.
• Assign a dedicated care manager. A nurse or care coordinator becomes the member's consistent point of contact — building a relationship, not handling one-off calls.
• Build and monitor a care plan. A personalized plan tracks medication adherence, appointment follow-through, and self-management goals, with regular outreach to check progress.
• Coordinate across the care team. The care manager bridges primary care, specialists, and behavioral health, closing the communication gaps that let conditions slip between visits.

Where do programs stall? Usually when they spread thin across a broad, low-intensity population instead of concentrating on the members most likely to benefit.

Key Metrics and Benchmarks

Your care management program's performance typically shows up in five areas:

• Hospital readmission rate
• Emergency department utilization
• Medication adherence rate
• Clinical markers (HbA1c for diabetes, for example)
• Member engagement rate — the share of enrolled members actively participating rather than opting out

Remote patient monitoring layered into care management has been shown to reduce hospital readmissions by up to 50% for conditions like heart failure and COPD. That's why health plans increasingly pair human care managers with connected devices rather than relying on phone-only outreach.

In 2026, remote monitoring is being deployed across post-acute, transitional, and hospital-at-home settings — reinforcing care management as a hybrid human-plus-digital function.

Where the Model Is Heading

Care management in 2026 is shifting toward tech-enabled, tightly targeted support for high-risk patients. Electronic Health Record (EHR)-linked workflows, AI-supported outreach, and connected care platforms are reducing manual coordination burden. Meanwhile, advanced primary care management models tied to value-based reimbursement are pushing proactive chronic disease management deeper into primary care.

Population stratification is getting sharper. Care teams are focusing on high-need members rather than broad low-intensity outreach — a direct response to research showing that generalized, high-volume activity doesn't reliably move outcomes or spending on its own.

The through line: care management delivers results when it's measurement-driven, tightly targeted, and integrated with your clinical and administrative operation. Running it as a standalone contact center doesn't get you there.

What's Your Next Step?

If your care management program isn't producing measurable reductions in readmissions and emergency utilization, the fix usually isn't more outreach — it's sharper stratification, dedicated care manager relationships, and connected monitoring tools that flag risk before it escalates. Start by auditing where your highest-cost members are falling through today.

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