Care Coordination

Every member that participates in the CareSource PASSE™ program receives care coordination.

The Care Coordination model is member-centered and member driven. Our Care Coordinators work directly with each member to identify who the member would like to be part of their Person-Centered Team (PCT). The PCT is typically comprised of:

  • Behavioral Health Provider(s)
  • Familial/Community Supports
  • Family Service Workers (if applicable)
  • Intellectual & Development Disability Service Provider(s) (if applicable)
  • Outreach Specialists
  • Anyone else the member identifies as a paid or unpaid support

The Care Coordinator will support the member and facilitate the PCT by:

  • Assessing each member’s needs
  • Developing, implementing and monitoring the person-centered service plan (PCSP)
  • Educating the member and their caregiver/family
  • Monitoring of services
  • Establishing linkage not only to paid providers but free community resources such as family service agencies, court systems, local mental health agencies, food banks, schools, pharmacies, primary care doctors and other appropriate paid and non-paid resources.

We stress the importance of helping the member thrive in the least restrictive environment possible by connecting members to appropriate services & community resources, identifying barriers, keeping appointments, building a strong support network and meeting each member’s unique needs. We also have pharmacists on staff to assist with medication reconciliation and function as a part of the interdisciplinary care team.

Providers are integral in the development of a member’s PCSP. You can request a copy of a member’s PCSP by emailing Care Coordination at

Care Coordination Enrollment

All CareSource PASSE members are assigned a designated Care Coordinator who will be their point of contact for all care coordination needs. Members should expect outreach from a member of the care coordination team within the first week of enrollment in CareSource PASSE. If, however, a member is unable to reach their assigned Care Coordinator or have not had contact with them yet, they can call Member Services to receive care coordination services at 1-833-230-2005, Monday through Friday, 8 a.m. to 5 p.m. Central Time (CT).

Identifying a Member’s Assigned Care Coordinator

Providers may call Provider Services to identify who a member’s Care Coordinator is or to speak to a Care Coordinator Supervisor. Providers may also identify a member’s Care Coordinator on the Provider Portal or by emailing

Members can call 1-833-230-2005 24 hours a day, seven days a week to access care coordination services.

Disease Management Programs

Our free disease management programs help our members find a path to better health through information, resources and support.

We help our members through:

  • The MyHealth online program for members 18+ to participate in a journey to improve their health.
  • Care coordination to provide disease management information and materials to members and providers with helpful tips to manage their disease, promote self-management skills and provide additional resources, as needed.
  • One-to-one care coordination.

Members with chronic health conditions are identified by criteria or triggers such as hospital admissions, initial health questionnaire as well as ongoing outreach and Person-Centered Service Planning. All ages (children, teens and adults) are eligible. The member’s Care Coordinator works with the Disease Management team to distribute information to members and providers. Any member may self-refer or be referred into disease management programs to receive condition-specific information or outreach. If members do not wish to receive materials or outreach, they can call 1-844-438-9498.

How to Refer Members to Disease Management Program

If you have a patient with a chronic health condition who you believe would benefit from a program and are not currently enrolled, please call 1-844-438-9498.

Provider Resources