li>Tailors interventions that are multi-faceted, improve quality and cost effectiveness to meet the patient's need while respecting the patient's role as a decision maker in the care planning process: Effectively uses the following tools/strategies that include, but are not limited to: evidence-based guidelines and practices, interactive care plan developed based on patient-set priorities where applicable, collaboration with multidisciplinary care teams, meet medical home (PCMH) requirements, physical/behavioral health integration, and patient self-management education and training. Other duties of the RN Care Manager include, but are not limited to, consultation with members on their medications and durable medical equipment, review member care plans, address home care needs, and connect members to community resources; collaboration with primary care physicians and other providers to ensure there are no gaps in care; collaboration with members, providers, and care givers to ensure positive care outcomes during care transitions.