Achieves optimal levels of wellness in the targeted patient populations through participation in the development of a plan of care that improves the patient's basic understanding of his/her disease process under the supervision of a Care Manager and in conjunction with patient/family, physicians and other health care team members, increasing provider awareness and participation with recommended treatment modalities, Monitoring patient's condition and addresses lifestyle issues, Participating in the transition of patients from disease management to care management when specific patient indicators exceed the established threshold, Attainment of increased compliance with treatment regimen, Uses knowledge of health system and community resources to facilitate achievement goals, Provides health education, identifies barriers to attainment of self- management goals and develops strategies to overcome, Reduces emergency room utilization and frequency of inpatient admissions, Reduces and delays late-stage disease manifestations. If operating in the PASO capacity, team member will utilize both the Spanish and English languages, work collaboratively with PASOs, Access Health and a multi-disciplinary team of health care providers to manage Hispanic patients identified with chronic conditions or at risk for chronic conditions to achieve efficient and effective care delivery through disease management.