a) Determination of high-risk individuals and use of client information to define level of participation in care management services
b) Assessment of preliminary service needs and treatment plan development, which will include goals, preferences and optimal clinical outcomes.
c) Assignment of health team roles and responsibilities
d) Development of treatment guidelines that establish clinical pathways for health teams to follow across risk levels or health conditions.
e) Monitoring of individual and population health status and services used to determine adherence to or variance from treatment guidelines
f) Development and dissemination of reports that indicate progress toward meeting outcomes for client satisfaction, health status, service delivery and costs.
g) Comprehensive transitional care from inpatient to other settings, including appropriate follow-up.