Guidelines for Identification and Care Management of Complex Patients

PurposeTo fulfill PCMH 4A: Identify

Patients for Care ManagementEstablish and reinforce a team-

based, interdisciplinary approach to patient care

Track and follow patient by case rather than by condition to ensure patient-centered care and reduce redundancies

Scope1. Behavioral Health Conditions

◦ Dementia / Alzheimer’s Disease, adult and pediatric patients with special needs

2. High Cost / High Utilization◦ Hospital re-admission within 30 days, expensive medication (e.g. anti-

viral for hepatitis and synagis)3. Poorly Controlled / Complex Conditions

◦ Age 64 and younger with DM, Hgb A1c ≥7 and urine micro-albumin ≥30ug/mL for two consecutive tests;

◦ DM patients with BP reading 140/90;◦ DM patients with Hgb A1c ≥9;◦ Hypertensive patients with BP ≥160/100 for two consecutive readings

4. Social Determinants of Health◦ New immigrant, uninsured with complex or multiple chronic conditions,

homeless5. Referral by practice staff, patient, family or caregiver for

patients that may be deemed beneficial for care management service.

Identification Process

Care Manag

er

Provider

Nsg/FHW

SW/MH

Tools:- IM / PED Care Management form- Existing disease-based registries & reports (e.g. DM,

HTN, dev delay)- Existing High Risk registry- Case discussion among care team members

Care Management Process

Complex

Patient

Provider

Nsg/FHW

Ancillary Staff

SW/MH

Primary CareSpecialty ReferralTx Plan/Goal SettingCare Coordination

Pre-visit Planning F/U (Referrals, ER/Hosp)Health Education/CounselingCare CoordinationCare Coordination

Preventive Screenings/CSPQA

Social ServicesBehavioral HealthHousing/Public AssistanceInsurance Care Coordination

The Role of HR Care Manager

Add newly identified pts to HR registry

F/U with pt

Collaborate and f/u

with care team

Regular chart

review & QA

Manage & maintain

HR registry list