Resource Library

2019 Best Practice Awards Submission for Care Management Workflow

PHCN has made numerous improvements to its Care Management program over the last year that has enabled the department to grow and reach a larger number of patients. This has included improved workflows, appointment availability at all primary care locations, medication management, and care coordination with the PCP. There are written workflows for major illnesses and planned visits; nutritional education following ADA standards, self-management goal education, and access to community resources.

2019 Best Practice Awards Submission for Care Management Workflow

OSP's information technology team developed an all-program inclusive care management patient roster by practice unit. The All Program Care Management Patient Roster assists practices and care managers identify eligible patients for care management. The IT team also built a care management Population Practice Engagement Dashboard, which publishes current rates of patient engagement in active care management programs for individual practices. The patient roster and engagement dashboard are unique in that they provide comprehensive patient eligibility for care management payer programs and real-time care management program engagement at a practice level.

2019 Best Practice Awards Submission for Care Management Workflow

As part of a pilot, OPNS had previously embedded an RN care manager in two primary care physician practices. The pilot was successful in that the care manager, physicians, and other care team members were able to create processes to identify appropriate patients for care management interventions, create patient panels, utilize the EMR to accurately document care management interventions, and bill PDCM services for eligible members.

2019 Best Practice Awards Submission for Care Management Workflow

The Care Management program was underdeveloped and underutilized. Structure was added to the program via oversight, constant monitoring, and marketing of services to patients and staff. Patient referral mechanisms were implemented and tweaked, including automatic referrals, to increase the number of patients seen by Care Managers. From 2016 to 2018, five times as many patients have been seen in the CM program.

2019 Best Practice Awards Submission for Care Management Workflow

The Diabetes Care Model creates the opportunity to improve patient care while developing a standard care management approach across the continuum. Patients with an elevated A1c are identified and assigned a lead care manager. The care management team meets to discuss the complex patients and care plans. The care managers provide invaluable coaching, goal setting, care coordination, and support for patients and their families across the care continuum.

2019 Best Practice Awards Submission for Care Management Workflow

Michigan Medicine implemented a hypertension best practice advisory in the electronic medical record by creating an automated visual when an elevated blood pressure is documented. By creating a workflow to properly identify patients with elevated BP, automate an order within the EMR to follow up with a pharmacist and schedule them for their follow-up appointment before they leave their PCP office, the team was able to achieve better follow-up time frames and overall BP control improvements.

2019 Best Practice Awards Submission for Care Management Workflow

The first part of the program was researching the care management capabilities and functionalities within Epic. The second part of the program was to take the information gathered and create the workflow within the system. Outcomes included standardized note templates, adoption of additional tools/resources, integrating external claims data into the plan of care using the data warehouse, and having the care manager workspace open directly to the longitudinal plan of care. The final part of the program was implementation and providing education and training to the practices.

2019 Best Practice Awards Submission for Care Management Workflow

Two key elements were included in the program: 1) Engaging key stakeholders and 2) Centralized Care Management for patients admitted to and discharged from a Skilled Nursing Facility. Engagement occurred through the application of consistent performance standards and transparent reporting as well as quarterly on-site meetings. The adoption of information technology was critical for the development of workflow including the use of ADT connectivity. In addition, an SDoH tool was developed, weekly collaboration/communication occurred, and a Transitional Care Management program was utilized.

2019 Best Practice Awards Submission for Care Management Workflow

The Team-based Care Playbook serves as a guide to assist with carrying out the daily tasks and functions that a Care Manager is asked to do. It addresses members of the care team that they can call on for expertise or delegation. Chapters are based on measureable tasks including Patient Empanelment, Longitudinal Care Management, Advanced Care Planning, Team-based Care, Social Determinants of Health, Payer List/PDCM, and Epic workflows. Establishing a standardized workflow for Care Management tasks and placing them within the playbook has allowed a level playing field for everyone to know what is expected.

2019 Best Practice Awards Submission for Care Management Workflow

Through the use of Jackson Care Hub, care coordination staff can more efficiently connect patients with community resources. The workflow also streamlines how Care Managers refer patients to the Community Navigation Specialist. The partnership between JHN and Central Michigan 2-1-1 for community navigation services provides an environment which allows Care Managers and Community Navigation Specialists to best utilize their respective skills.