Concept: Care Management and Support...CM05: Providesa written care plan to the...
Transcript of Concept: Care Management and Support...CM05: Providesa written care plan to the...
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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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