Indian Health Service (IHS) is accepting applications for the Public Health Nursing (PHN) cooperative agreement. The purpose of this IHS cooperative agreement is to improve specific health outcomes of an identified high risk group of patients through a community case management model that utilizes the PHN as a case manager. Research indicates nursing case management is a cost effective way to maximize health outcomes. Case management involves the client, family, and other members of the health care team. Quality of care, continuity, and assurance of appropriate and timely interventions are also crucial. In addition to reducing the cost of health care, case management has proven its worth in terms of improving rehabilitation, improving quality of life, increasing client satisfaction and compliance by promoting client self-determination. The PHN model of community based case management utilizes roles and functions of PHN services of assessment, planning, coordinating services, communication and monitoring. The goals and outcomes of the PHN case management model are early detection, diagnosis, treatment and evaluation that will improve health outcomes in a cost effective manner. This model utilizes all prevention components of primary, secondary and tertiary prevention in the home with patient and family. The community based case management model addresses the PHN scope of practice of working with individuals and families in a population-based practice to provide primary nursing care services. This project will focus on a PHN community based case management model. The project will be conducted in a phased approach, using the nursing process - assessment, planning, implementation, and evaluation.