Creating Care Management Plans

An important aspect of the New York State Delivery System Reform Incentive Payment (DSRIP) Program will be the implementation of care coordination and transitional care programs. This can be accomplished by integrating primary care providers, case management agencies, health homes, and the patients themselves.

CNYCC’s goal is to empower its partner organizations and their employees with the necessary skills to deliver a training plan and provide resources for effective care management principles. The Care Coordination program aims to provide support and a central care coordination resource to educate partner organizations and their employees create a care plan, coordinate care and engage patients.

CNYCC will be providing a series of educational resources and tools related to care coordination for PPS partners.

The purpose of the Creating Care Management Plans course is to understand patient’s care needs, goals and what is important to him or her. Partner organizations will learn how to write a Care Plan and when it is appropriate to update a Care Plan as well as how to coordinate a team and service meeting to deliver more comprehensive care management/care coordination services.

The goal of the Creating Care Management Plans is for partner organizations to demonstrate an understanding of the importance of the Care Plan and collaboration with the individual and family/caregivers in care coordination/care management and its correlation to patient outcomes.

CNY Care Collaborative's Creating Care Management Plans Course Overview

Course Description:

This course will help organizations develop a comprehensive care management plan for each patient to engage him or her in his or her care and to reduce patient’s risk factors. Participants will learn how to create a care management plan and use the care management plan to guide care management activities. Participants will also be able to identify and distinguish what is important to and for the patients.

Course Objectives:

At the end of CNYCC’s Creating Care Management Plans course training, participants will be able to: 

  • Create a care plan from beginning to end.
  • Understand how to use the Care Plan to guide Care Management activities.
  • Understand how to identify or distinguish what is important to and for the patient.

CNYCC Performance Activity or Milestone

The Creating Care Management Plan course would satisfy the reporting requirements for DSRIP Care Management/Health Home At-Risk Intervention (Project 2.a.iii) Milestone #6: “Develop a comprehensive care management plan for each patient to engage him/her in care and to reduce patient risk factors.”

Partner Organizations not assigned this milestone are invited to utilize the course as a resource, if desired.

CNYCC “Creating Care Management Plans” Course

CNYCC partner organization employees will have access to CNYCC’s Creating Care Management Plans course via HWapps, CNYCC’s online Learning Management System licensed from Health Workforce New York (HWNY). The course includes one 39-minute interactive video and a post-course evaluation.

Below you will find instructions on how partner organizations and their employees can access the Creating Care Management Plan course through HWapps:

Partner organizations will be asked to identify a Partner Administrator that will manage the training process for their employees, unless previously identified.

The Partner Administrator will be provided access to the HWapps Partner Administrator portal and may distribute the training to individual staff members (via the link below).

Once staff members click the link to access the course, they will be asked to sign in (if they have registered for a previous CNYCC course) or register as a new user. After signing in, participants can select Creating Care Management Plans to begin the course.

Staff members will then be required to view the entire interactive video presentation and complete the post-course evaluation.

Partner Administrators will have the ability to view and monitor the course completion status for their organizations’ employees through the HWapps Partner Administrator portal.

Please click the following link to CNYCC’s Creating Care Management Plan Course:

Additional Completion Opportunities for Creating Care Management Plans Course Requirements

If your organization would like to import the eLearning modules into your own Learning Management System or if your organization has limitations that will prevent employees from accessing embedded videos with audio, please contact

For questions related to access for CNYCC’s Patient Identification and Hypertension Visit Scheduling Course, please contact

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