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Concept: Care Management and Support• The practice identifies patient needs at the individual and population

levels to effectively plan, manage and coordinate patient care in partnership with patients/families/caregivers. Emphasis is placed on supporting patients at highest risk.

• 2 Competencies• 9 Criteria:

• 4 Core• 5 Elective (6 credits)

• 2 New to 2017 criteria

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• Competency A: The practice systematically identifies patients who may benefit from care management

Care Management and Support (CM)

Criteria Core Elective # Credits

CM01: Considers the following when establishing a systematic process and criteria for identifying patients who may benefit from care management (at least 3)

X

CM02: Monitors the percentage of the total patient population identified through its process and criteria

X

CM03: Applies a comprehensive risk-stratification process for the entire patient panel in order to identify and direct resources appropriately

X 2

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CM 01 (Core)

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• Engagement is directly correlated to relevance

CM01: (2014 equivalent = 4A1-5)

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CM 02 (Core)

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CM02: (2014 equivalent = 4A6)• Should be <10% of whole population• Continue to monitor• Not all sites are created equal

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CM 03 (2 Credits)

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• Let’s talk about risk…..what does it mean?

• Do you have a Care Management plan?

CM03:

?

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• Competency B: The practice systematically identifies patients who may benefit from care management

Care Management and Support (CM)

Criteria Core Elective # Credits

CM04: Establishes a person-centered care plan for patients identified for care management X

CM05: Provides a written care plan to the patient/family/caregiver for patients identified for care management

X

CM06: Documents patient preference and functional/lifestyle goals in individual care plans X 1

CM07: Identifies and discusses potential barriers to meeting goals in individual care plans X 1

CM08: Includes a self-management plan in individual care plans X 1

CM09: Care plan is integrated and accessible across settings of care X 1

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CM 04 (Core)

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• Define roles and responsibilities• Training, Training, Training• Necessary vs. Forced

CM04:

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Record Review Workbook

?

30 days back from date-

then first 30 pts. moving backward in

time

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CM05-08: Care Plans

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CM05-08: (2014 equivalent = 4B 1, 3, 4, 6)

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Care Plans and Everything Else PCMH: • TC: Who works with your CM patients? How does the care team communicate

about the CM patients? Do you have the right people to care for your CM patients?

• AC: What appointments do your CM patients need? What are alternate ways to communicate with your CM patients? Who is their PCP?

• KM: How can you identify your CM patients? What do your CM patients needs to be aware of? What SDH define your CM patients?

• CC: What referral sources do you need for your CM patients? Are your CM patients getting the services they need? Can your CM patients navigate the system?

• QI: Do your care plans result in improved quality? Do your care plans result in decreased utilization? Are there other conditions or measures that define care management populations?

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CM 09 (1 Credit)

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• HIT is critical• Pt. Engagement• Communication

on steroids

CM09:

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CM: Your Transformational Application

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BREAK