2019 Best Practice Awards Submission for Care Management Workflow
Care Management Team within the Primary Care Office is embedded within the Quality Department which allows for patient identification to help close gaps in care. The Certified Medical Assistant role is embraced where they are expected to work to the top of their licensure and assist with mildly complex patients who have needs related to Care Coordination. Certified MA's follow patients who qualify for Care Management based on risk score and/or disease stage whose insurance does not cover Care Management Services. Systematic approach for identifying patients based on lab values, gaps in care, ED/Inpatient stays, blood pressure values, and SDoH needs. Providers are engaged and understand the benefits and importance of the program. Open and frequent communication with the Care Team is expected.