Care management, one of the cornerstones of the patient-centered medical home (PCMH), focuses on both wellness and illness. Directed at patients with long-term and/or complex care needs, it encompasses prevention and patient education, as well as treatment of acute sickness and/or injury. Care management means comprehensive care, addressing a person’s psychosocial and spiritual well-being, as well as physical health.
A PCMH that manages patients’ care ensures that:
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Every patient has an individualized care plan;
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Each care team member has access to patients’ care plans;
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Care is standardized according to clinical guidelines;
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Care team members work as a group; and
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Each team member knows her/his role in providing care.
Care management aims to turn acute, episodic care into planned care. For example, to forestall breathing difficulties in an asthmatic patient and potential visits to the emergency room, the PCMH care team carefully monitors her medications. They work with her to determine her asthma triggers so she can avoid them, and teach her self-management techniques. The care team establishes regular office visits to assess the patient’s lung function and the effectiveness of her medications. The goal of both the team and the patient is to help her attain control over her condition and enjoy a high quality of life.
Thus, care management:
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Turns acute, episodic care into planned care;
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Focuses on high-risk, high-cost patients; and
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Emphasizes prevention, disease management and patient engagement.
Technology assists care management. A patient registry allows a practice to identify all patients needing care management, such as those with asthma, high blood pressure, diabetes or coronary artery disease. Clinicians can devise and apply care plans for these populations, including regular office visits, screenings, medication monitoring, tests and appointments with specialists. The registry helps them schedule and track this care. An electronic health record (EHR) allows the care team immediate access to patient data and secure sharing with other providers.
Top care-management practices include:
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Multidisciplinary care teams;
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Pop-ups on the EHR to alert the care team about patients due for exams, lab work, etc.;
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Staff roles adjusted to give patients focused, personalized care;
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Online patient portal allowing quick access to the care team, scheduling and test results;
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Labs drawn in advance so the care team can focus appointment time on treatment and patient education;
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Team huddles prior to appointments, so all members know the care plan and their roles in promoting it;
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Checklists to ensure thorough care; and
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Program evaluations to ensure quality care.
The National Committee for Quality Assurance lists care management requirements in its 2011 PCMH standards.1 To identify and manage patient populations, a practice must:
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Collect demographic and clinical data for population management;
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Assess and document patient risk factors; and
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Identify patients for proactive and point-of-care reminders.
For individual patients, a practice must:
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Perform previsit planning;
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Assess progress toward treatment goals;
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Address barriers to achieving treatment goals;
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Reconcile medications at each visit and after hospitalization; and
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Use e-prescribing.
Care management, integrated into a practice’s daily flow, will produce better outcomes, more satisfied patients and providers, and reduce the frequency of costly emergency room visits and hospitalizations.
Source
1. National Committee for Quality Assurance. Comparison: PPC-PCMH 2008 with PCMH 2011. www.ncqa.org/LinkClick.aspx?fileticket=RdzaHTOsgxI%3D&tabid=1412, pp. 3-4.