What We Do

Our care management services focus on helping people with chronic health conditions, complex needs, behavioral health, dementia care, and more. You will work with a DukeWELL care manager to create a personalized care plan to help you meet your health goals. We help coordinate your care and improve your ability to access the care you need, when you need it. 

Many of our DukeWELL patients are living with conditions like:

• Heart disease & heart failure
• High blood pressure
• Diabetes
• Lung disease/COPD
• Asthma
• Kidney disease

We work as a team with you and your providers to communicate and coordinate care. We’ll also connect you to other members of the DukeWELL team or community resources if you need them. 

Our goal is to take care of the whole person, not just your condition. We’re here to help you feel supported and empowered in your health journey.

Specialized programs for Care Management:

• LATCH supports the under/uninsured in Durham County to ensure they have access to appropriate care. Click here to learn more about LATCH.
• DukeWELL helps Duke patients access Social Security Disability benefits through the SOAR program. We work with patients throughout the process to apply, obtain documentation, and follow-up.
• NC InCK helps improve care delivery and support for Medicaid-insured children up to age 21 and their families in Alamance, Orange, Durham, Granville, or Vance counties.
• DukeWELL is an AMH+ Care Management organization that is qualified to support patients from AMH+ practice sites who have both medical and behavioral health needs and are on an Alliance tailored plan.
• Duke’s Foster Care Clinic and DukeWELL partner with Durham and Orange County Social Services to provide care and support to children who enter foster care.
• DukeWELL provides care coordination services and connection to medication assisted treatment for patients with Opioid Use Disorder.

The journey to good health starts with prevention – and DukeWELL is here to help! We work with patients of all ages to help them stay connected to their primary care provider. We also work in the community to connect patients to preventive healthcare and services.

If you need help getting primary care, our team can:

• Connect you to a primary care provider if you don’t have one
• Schedule wellness visits or well child checks and immunizations
• Schedule annual screenings like mammograms or colorectal cancer screenings
• Connect you to community events that offer healthcare services

We also support people in maintaining healthy habits, including a smoking cessation program and diabetes prevention.

DukeWELL has a dedicated team of pharmacy professionals who will work with you to improve your ability to understand and take your medicine correctly. 

DukeWELL can assist you with:

• Getting a complete history of your medicine
• Understanding your medicine
• How to safely and correctly take your medicine
• Connecting you with resources for assistance in getting your medicine
  • Financial assistance programs
  • Transportation or delivery options
  • Insurance approval

Our team of pharmacists and pharmacy techs will connect with your providers and other members of your care team when needed to share knowledge and support you as you pursue your health goals.

DukeWELL’s Care Transitions team works with patients who are transitioning between care sites, including community facility placement. Our team will work with you to improve outcomes during transitions and avoid unnecessary readmission.

Our team of professionals conducts thousands of hospital follow-up calls each year. We assess your needs and help:

• Schedule follow-up appointments with your primary care provider
• Get you connected to community resources for help with food, transportation or other needs
• Connect you to home health when needed
• Help you understand hospital discharge instructions
• Connect you to resources for understanding your medicines

Our care transitions team works collaboratively with your other care team members to support your needs during this time.

Many patients have needs that aren’t medically related, but still affect their ability to be as healthy as possible. Because DukeWELL cares about your whole health, we will assist you in addressing these other needs.

Our DukeWELL team works with over 400 community organizations, and offers expertise in finding and connecting you to resources. Here are some of the areas where we can assist:

• Food insecurity
• Transportation
• Housing instability and utility assistance programs
• Financial stress
• Educational opportunities
• Family and community support

We will work to connect you to the support you need so that you can improve your chances of meeting your health goals.