Care Management

As a practice within the OhioHealth Clinically Integrated Network (CIN), you have access to and can benefit from clinical programs that are designed to improve patient health and produce efficiencies in patient care delivery.

CIN leadership and practicing physicians are leading the charge to create evidence-based guidelines and meaningful clinical interventions – some of which are listed below.

High Risk Care Management
OhioHealth Care Management plays an integral role in helping CIN practices meet certain incentive activity requirements surrounding high risk populations.

High risk patients comprise a small amount of patient panels but account for a large amount of resource utilization. In collaboration with CIN providers, our high-risk programs identify and connect patients with extensive healthcare needs to Care Management for proactive outreach, creating better patient health, more affordable care, higher quality care, and a stronger health delivery system.


Emergency Department (ED) Utilization
As we continue to explore ways of reducing inappropriate use of EDs, this program seeks to educate patients who visit the ED more than twice in six months and connect them with appropriate resources, such as a Primary Care Physician or Urgent Care.


Transitions of Care
This program is designed to reduce avoidable readmissions within 30 days post-discharge through hands-on coordination of care, education and leveraging evidence-based guidelines across the continuum.


Chronic Disease Care Management
Our care management program is expanding, from a high-risk patient focus to one that also encompasses low and rising-risk patient populations where we have opportunities to make significant strides. Their efforts will focus on multiple conditions, including chronic heart failure (CHF), chronic obstructive pulmonary disorder (COPD) and chronic kidney disease (CKD).


Diabetes Care Management
This program includes the Diabetes Prevention Program, which attempts to prevent the progression of patients with prediabetes, and extends to comprehensive management of those with diabetes and associated conditions.


Medication Therapy Management
This program is designed to help patients effectively manage their medications through a partnership between you, your patients and CIN clinical pharmacists.


For more information about these programs, please call (614) 566.0003 or (877) 644.7469 (toll-free).