Two programs extended the traditional DCCO roles of care manager, co-locating them in primary care and behavioral clinical settings with results beneficial to care managers, providers and patients. One program was established in Vermont, focusing on improving the health states of persons with severe, persistent mental illness (SPMI) with a co-morbidity of diabetes. The second program serves over 400 high-risk Medicaid beneficiaries with disabilities and chronic disease in Springfield, MA. Both initiatives required overcoming the challenges found among differing provider specialty cultures, insufficient organizational supports and consumer behaviors that commonly defeat their self-management of their health and life needs.

The outcomes of both projects are encouraging and hold import for care management practice, for primary care and behavioral health providers, the systems in which they practice, and to DCCO beneficiaries. The nurse and social worker care managers and the providers in both systems built positive professional relationships, gained insights into the knowledge and practices of specialties different from their own, and leveraged each other’s expertise more positively to the benefit of patient care. Organizational systems gained insights into the supports needed to achieve optimal integration and comprehensive care. Outcomes for patients were significant: enhanced abilities to manage their complex health and life situations and realize improved health states.