From transitions of care to lifelong support
In 2025, MultiCare Medical Associates (MMA) Primary Care expanded the ways we support patients and families throughout their health journeys. Our care managers — who are registered nurses — have long helped patients safely transition from the hospital back home. Building on that strong foundation, we expanded our support to include ongoing care for chronic conditions and the social factors that shape health every day.
Strengthening chronic disease care
RN care managers focused on building deeper expertise in diabetes care, strengthening how patients are supported across primary care. A new, standardized diabetes management workflow was introduced to ensure patients receive consistent, evidence‑based support across clinics.
Nurses also expanded their training in continuous glucose monitoring (CGM), helping them better guide patients through diabetes management. The team completed a comprehensive 16‑hour diabetes education series, further strengthening clinical skills and documentation practices.
Through this work, RN care managers completed 1,208 patient visits, primarily focused on diabetes and hypertension care. An additional 220 co‑visits — where providers and RN care managers saw patients together — supported stronger collaboration and created a more connected, team‑based experience for patients.
Supporting the whole person
Because health is shaped by more than medical care alone, MMA launched the Community Health Worker (CHW) program to help patients navigate everyday challenges that can affect their health and recovery. Community health workers are embedded in clinics, where they support patients with housing, transportation, food insecurity and other social needs.
Today, four CHWs support patients across 25 clinics, working alongside a growing RN care manager team that expanded from 13 to 15 nurses. Together, these teams provide more coordinated clinical and social support for patients and families.
To expand access to these services and support long‑term sustainability, MMA also began billing eligible CHW services — helping ensure more patients can receive the support they need.
We also strengthened partnerships to improve care:
- Pharmacy: Access to the Medication Assistance program was streamlined, creating smoother handoffs for patients who need help with medication costs, adherence and reconciliation — all fully integrated into the diabetes care workflow.
- MultiCare Eldercare Family Services: A direct referral pathway was created, making it easier for older adults and caregivers to access aging and disability resources, coaching and in‑home support. These services help address transportation needs, daily living challenges, caregiver stress and safety concerns alongside medical care.
Looking ahead
In 2026, the MMA Primary Care Population Health team will continue building a care model that supports patients through chronic disease management, expanded social‑needs services and refined transitional care. By combining clinical expertise with community‑based resources, we’re meeting patients where they are — and helping them stay well in their communities.
Want to learn more or partner with us?
Discover how the MultiCare Medical Associates Population Health team is transforming chronic disease management. Contact us at [email protected] to collaborate, share ideas or explore how these programs can benefit your patients and community.
Written by: Jose Mari Lansang, RN, Director of MultiCare Nursing for Primary Care & Population Health