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Care Planning provides the learner with the necessary elements, purpose, framework and skills for care management team members to develop a high quality patient-centered plan of care. The learner will also be able to apply knowledge from the care planning lesson to a case study.
The expected time to complete this module is 60 minutes.
Lesson 1: The Patient-Centered Care Plan
Objectives:
In 2020, MICMT will be launching new course curriculum to include: Introduction to Team Based Care, Patient Engagement, MAT Orientation, Palliative Care, and Specialty Care. The presentation reviews the new framework, training opportunities, and training reimbursements.
2019 Best Practice Awards Submission for SDoH
A plan was developed as a healthcare system which guaranteed that patients with or without a network primary care provider were seen for follow-up with seven days of discharge. This was accomplished by: 1) maintaining designated appointments on PCP schedules every day; 2) scheduling patients with the hospital based clinic provider for hospital follow-up if their PCP could not accommodate the appointment or the patient did not have a PCP; and 3) developing a transition plan to a network PCP for patients who did not have one prior to accessing hospital services.
2019 Best Practice Awards Submission for SDoH
There was an identified need to screen all patients for SDoH, as previously only screening patients who were receiving care management services. The PRAPARE questionnaire was designed on the iPad for patients to complete during check-in process to minimize impact on time in exam rooms. Patients with issues identified through the screening met with either a care manager or community health worker through a warm handoff, and were provided support or connected to community resources as needed.