Aetna nurse case managers worked with doctors in 36 primary care practices, coordinating care to help members monitor and manage their health conditions. They also helped members and doctors use personal health records as a communications and tracking tool. ActiveHealth 's CareEngine ® System identified and alerted the care team to actionable gaps in a patient's care. Aetna then helped pair the doctor groups with specialists, hospitals and community social services such as state departments on Aging for in-home services, home-delivered meals, caregiver support and respite care, and other community services.