Overview
AHP’s RN and Social Work Care Managers play vital roles in enhancing patient care by providing comprehensive support to pediatric, internal, and family medicine providers and their patients. Our Care Managers work closely with the AHP Behavioral Health Integration and Pharmacy teams to provide comprehensive support, integrating expertise from several domains to impact three key foci of care management: transitions of care, complex care management, and population health.
Three Foci of Care Management
Transitions of Care (TCM)
Supporting vulnerable patients who are transitioning between Hospital/SNF to home, hospice, alternate level of care (ALC)
Complex Care Management (CCM)
Supporting patients with multiple, chronic diseases, with or without mental health diagnoses who are not progressing clinically
Addressing Gaps in Care (Population Health)
Care Management Leadership
Danielle Calder, DNP, RN-BC, CNL
Director, Adult Care Management
Robin McElligott, LCSW- R
AHP/CMO Clinical Manager, Maternal Child & Family Care Management
Catherine Wightman
Program Director, Lactation Care Management
Adult Care Management
RN Care Management
AHP’s RN Care Managers partner with internal and family medicine providers and their patients to provide:
- Care Coordination: Ensure smooth transitions between different levels of care, reducing readmissions and improving patient outcomes. Provide specialized support for patients with complex medical conditions, ensuring comprehensive management and follow-up.
- Education and Counseling: Educate patients on health conditions, treatment options, and self-management strategies.
Pediatric Care Management
Social Work Care Management
AHP’s Social Work Care Managers support pediatric providers and their patients to provide:
- Care Coordination: Collaborate with healthcare teams to develop and implement care plans. Ensure continuity of care and follow-up for patients, particularly those with chronic illnesses or complex health needs. Assist patients in navigating complex healthcare processes and resources.
- Addressing Social Drivers of Health: Assess and address factors affecting patient health to connect them with community resources.
Pediatric Community Outreach
Under the Pediatric Social Work Care Management umbrella, the Pediatric Outreach Team, collaborates with care managers and their practices to support children and families facing barriers to accessing basic resources such as food, clothing, housing, financial and social services, insurance, infant care items, dental care, developmental evaluation, behavioral health and substance abuse counseling, and transportation. They bring diverse experience in community-based work with children and families, including areas such as family services, domestic violence, children’s health home care, developmental disabilities, and behavioral health care.
Lactation Care Management
Accountable Health Partners offers a patient-centered and community-responsive Lactation Care Management program designed to expand access to appropriate lactation care and breastfeeding/chestfeeding support and to help families offer optimal nutrition to their newborns and young children.
The LCM program is designed with flexibility to meet the needs of individuals and their families. Families are provided with education, practical clinical support, and care coordination as needed. To meet the unique needs of each family, individuals may meet more or less frequently with their lactation care manager, and support can be provided in person or by phone. Parents enrolled in LCM may meet with an International Board Certified Lactation Consultant (IBCLC) at their participating OB/GYN practice, at Noyes Hospital at the time of delivery, or a participating pediatric office.
Data Coordination
AHP’s Data Coordination program continues to strengthen collaboration, streamline workflows, and support providers across our network through ongoing use of enhanced tools—including Health Catalyst. By integrating EMR and claims data, we are improving our ability to identify care gaps, prioritize patients, and align outreach with practice workflows while supporting value-based contract goals. We are also deepening our work to address health-related social needs through close partnerships with AHP Care Management and Forward Leading IPA, creating a more connected, patient-centered approach.
Current Care Management Initiatives
Social Care Networks (SCNs)
The establishment of Social Care Networks (SCNs) is a core part of the NYHER Amendment. New York State has established 9 regional Social Care Network Lead Entities who are responsible for building a robust Network of Community-Based Organizations (CBOs) and other organizations providing health-related social needs services and coordinating with health care providers (inclusive of behavioral health and primary care providers). Together, each Social Care Network is responsible for ensuring that there is a seamless, consistent, coordinated, end-to-end process in their region for Screening, Navigation, and delivery of health-related social needs services. This requires close collaboration within each Network, as well as shared data and technology provided by the State. Social Care Network Lead Entities also engage a broader ecosystem of partners to achieve their goals, including health insurance plans, local government, and child & family supports. AHP has partnered with Lead Entity, Forward Leading IPA (FLIPA) to accomplish this work.
Chronic & Complex Care Management Program
The Chronic & Complex Care Management (CCM) program strengthens patient support by moving beyond a referral-only model to a proactive, population-health approach. Using embedded, centralized, and hybrid care management designs, we identify and engage at-risk patients earlier, improving outcomes, reducing avoidable utilization, and supporting patients where they live. Our work is guided by standardized, Epic-integrated pathways, each with clear inclusion/exclusion criteria and guideline-aligned interventions. As we transition to a more structured model, eligibility is defined by disease-specific conditions, utilization patterns, and risk scores, ensuring that we focus on patients most likely to benefit. Additionally, providers and patients are supported by a multidisciplinary team, including RNs, Social Workers, and Data Coordinators who deliver coordinated clinical management, address social needs, and enable data-driven outreach across the population.
Five Contacts Transitions of Care Program
The 5-Contacts Program is designed to reduce unnecessary hospital readmissions through evidence-based care management interventions to reduce medication errors, primary care follow-up, and assisting patients with managing their conditions outside the hospital. The program includes the following contacts:
