Resource Library

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.

2019 Best Practice Awards Submission for Care Management Workflow

The groundwork for care management workflow began in 2009 and has since developed. There is a larger than average number of support staff, including three registered nurse Care Managers. During office hours, a designated Care Manager actively works on care management-specific tasks, and a secondary Care Manager answers phones or rooms patients as well as provides care management to patients if the other is busy.

2019 Best Practice Awards Submission for Care Management Workflow

IHA has implemented the Patient Activation Measure (PAM), an evidence-based tool for measuring a patient's level of engagement in their healthcare. It is designed to assess an individual's knowledge, skill, and confidence for self-management. PAM allows teams to predict which patients will have higher avoidable health care utilization and be more likely to develop a chronic disease. Care managing patients with lower PAM levels ensures that teams are working with patients that are high utilizers of heath care services and demonstrate a response to care management interventions.

2019 Best Practice Awards Submission for Care Management Workflow

HVPA created a care management program which provided different options for each office to be able to engage in care management and/or care coordination services. This included an embedded care manager leased from HVPA; centralized care manager leased from HVPA; or assisting with training a care manager or care coordinator hired by an individual office.

2019 Best Practice Awards Submission for Care Management Workflow

There have been hallmarks of Holland PHO's highly successful, fast-growing care management team that are indicative of the many workflow improvements Holland PHO has implemented including a subcommittee of care managers appointed to develop a network-wide policy and procedure that defines the scope of care management; implementation of program to allow for warm-hand off to PCP; the formation of a Care Transitions Team out of the hospital to improve readmission rates; collaboration with Skilled Nursing Facilities; care management targeting methodologies; reconciling care management encounters; and a focus on communication and network efforts.

2019 Best Practice Awards Winner for Care Management Workflow

Beginning in 2018, GLMA weaned all controlled substance use for chronic pain patients over a 15-month period while still retaining these patients to the practice. The total number of chronic pain controlled substance prescriptions was reduced from nearly 800 prescriptions per quarter to less than 50 per quarter, over the same time period. The success of this program relies greatly on the physician and care manager team management approach as opposed to other options such as Medication Assisted Therapy (MAT) programs.

2019 Best Practice Awards Submission for Care Management Workflow

After the conclusion of the Michigan Primary Care Transformation program, Clinton County Medical Center saw an opportunity to restructure its office staff, including care managers, into physician-led teams to offer care management to all patients who could benefit from it. Through the changes in workflow over an 18-month period, CCMC was able to substantially increase engagement in both Provider Delivered Care Management (PDCM) claims and overall longitudinal care management.