Table 1

Characteristics of Practice Facilitators and Care Managers

RoleCore FunctionsConnection to Practices and PatientsEducational Background
Practice facilitatorHelp the practice organize, prioritize, and sequence QI activities
Train practice staff to understand and use data to drive QI
Increase practice capacity for QI activities
Help build a team orientation among practice staff and a practice culture receptive to change
Share best practices and lessons across practices
Facilitator is typically employed by an external organization (not the practice)
Facilitator works with practice staff (not patients)
Facilitator typically works mostly on site at the practice with some interactions by phone, e-mail, or video conference; some facilitators work entirely virtually
Social work, nursing, counseling, health management, business, and other areas
Care managerAssess the patient’s care needs
Develop, reinforce, and monitor individualized care plan
Provide patient education and training in self-management skills
Coordinate patient’s care with other providers and settings, and communicate needed information
Connect patient to community resources and social services
Participate in practice QI activities
Care manager may be employed by the practice itself, a payer, or state. They are closely integrated into the practice team
Care manager provides services to patients and families
Care manager (as we define) works at the practice, and may also interact with patients by telephone, e-mail, in the patient’s home, or in other providers’ offices
Nursing, social work, counseling, and other areas
  • QI = quality improvement.