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Care Partners

Nurse Care Manager Program is a Benefit of BJC Accountable Care Organization

Remember when you were young and your parents made sure you ate right, saw the doctor regularly and took your medicine when you should?  That same type of care and concern is shown to patients by a special group of nurses and a social worker who keep in touch with their patients by phone. Have they kept their doctor’s appointment? Taken their medicine? Are they eating balanced meals and taking proper care of themselves?

Medicare patients of BJC Medical Group doctors have that service as a part of BJC Accountable Care Organization. Nurse care managers call patients when they are discharged from the hospital, or when they have been identified as being at a high risk of hospital admission due to chronic disease. 

The care management team is assigned to work with certain practices and providers within each region. They keep the physician updated through the patient’s electronic medical record.

According to the care managers, patients sometimes find it hard to reach their physician, or hesitate to call when they have questions. Because many care managers are nurses, patients feel comfortable calling to say “Is this something I should be concerned about?” or “Is there something I should do?”

Patients receive one to four phone calls, depending on their situation. Some patients, though, can continue to receive calls for months if the need is there.

Read some of our patient stories.