A distinguishing feature of the CCNC program is the emphasis on population-based health management and quality improvement initiatives. Clinical Care Coordinators conduct risk assessments, and operate targeted disease and care management activities. These initiatives include helping to identify patients with high risk conditions or needs, assisting the providers in disease management education and/or follow-up, helping patients coordinate their care or access needed services, and collecting data on process and outcome measures.

The components of CCPGM's disease management services include:

1. Identification of at-risk individuals through providers, use of the emergency room, hospital admissions, or through Medicaid claims data.
2. Development of disease management treatment plans, using standardized protocols where model programs are presented and nationally recognized practice guidelines are identified and implemented by local practitioners.
3. Education of the patient and his/ her family (as appropriate) typically provided by the patient's primary care provider, and/or by office staff or the CCPGM care Clinical Care Coordinators. CCPGM also offers classes or clinics targeted at the management of specific health conditions.
4. Provision of individualized care coordination services for patients by linking patients to community resources, and assisting to arrange transportation if needed to get to a doctor's appointment.
5. Collaboration with community agencies or providers to manage the patients' care. Every effort is employed to minimize any duplication of effort and to improve communication across agencies.
6. Collection of performance data and provision of feedback to individual practitioners, group practices and the local network. The CCNC Medical Management Committee has identified outcome and process measures to evaluate the performance of individual providers, practices, and the local network. Process measures may include periodic assessments of medical records and results obtained by randomized chart audits.