Coordination of care for the high-risk participant includes organizing, securing, integrating, and personalizing the healthcare resources necessary to accomplish the goals set forth in the care plan. Regular contact with the participant and the participant’s physician allows the RN Care Manager to obtain advice on care plans and manage episodes of clinical instability in an overall coordinating role. Though contact between the RN Care Manager and the participant is “need based”, strong emphasis is placed on the development of the one-on-one relationship between the participant and RN Care Manager to promote and reinforce education and compliance.