Care Management

Care management refers to clinical and administrative activities which systematically improve the delivery of health care services. Managed care helps people and their families engage in a collaborative process with health care providers in order to improve care coordination and achieve optimal health while receiving cost-effective, non-duplicative services. In the United States today, health care providers are often directed to identify and provide managed care services to people who are at higher "risk" because they offer the greatest potential for improvement in health outcomes ( However, because of our commitment to parity of care, HeartSong does not provide more services to one population than another.   Everyone who comes to HeartSong benefits from care management.  

Care Coordination

Care Coordination refers to the deliberate organization of your care among two or more participants (including you and/or your family) to make sure that you get the care that you need in a timely manner. It involves coordinating people and resources to carry out all required care. It is managed by the exchange of information among the people responsible for different aspects of the care. At HeartSong, your care is managed using both paper and electronic technologies, including phone, fax, email, and EMR.

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Care Transition

The term Care Transition is used at HeartSong to refer to administrative activities that are performed to ensure continuity of care when you come to HeartSong from another facility, or leave HeartSong for primary care elsewhere. Care Transition services include requesting records from other facilities and giving other practices access to your records at HeartSong.

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In addition to cooperating with other providers involved in your care, your physician collaborates with you and your family to ensure that: (1) you have all the information you need to make informed choices; (2) you have the self-awareness and confidence to actively participate in your care; (3) you have the support you need to complete your course of treatment, such as self-management tools, personal copies of your treatment plan, timely access to your personal health information, including medications (dosage, purpose), appointment reminders, access to appropriate community resources; and (4) you receive counseling around issues that might prevent you from achieving your personal health goals.

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Preventive Medicine Screenings

Regular testing to screen for certain chronic illnesses which can be prevented or more successfully treated if diagnosed early, such as hypertension (high blood pressure), diabetes, cardiovascular disease, is another part of care management at HeartSong.

HeartSong regularly performs regular preventive medicine screenings at various intervals according to current evidenced-based guidelines. These are tracked and recorded so that people who need the tests done can be identified and notified in a timely manner.

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Hear what people have to say about care management:

The one-on-one care is very nice and you remember who I am when I come in and I was so happy I brought my children and husband and they are happy and you remember who they are too.

I feel that just by coming here and talking with you about our problems and health and getting the information that we need to feel better and be healthier, we're just feeling so much better, even my husband who was reluctant to come because he doesn't like doctors, seems calmer.

Keri Roberts, Brattleboro