Self Assessment – How should we organize our care management activities?

  • What are our most important patient groups to be served by the care management efforts (patients for whom we can obtain
    payment, patients taking eight or more medications, patients transitioning from hospital to home, patients with more than
    two chronic conditions, patients currently requiring the most support from clinicians)?

  • How will our patients be referred to our care manager? Is there a formal yet simple process for staff/providers to refer patients
    to the care manager?

  • Do we clearly articulate to the patient receiving that the service is a choice? How will the care manager/practice document the patient agreement to the care management service, and where will this be located in the chart? Or is care manager as a team member just “how we do care” at our practice?

  • How will team members know a patient is receiving care management services and when the service has been discontinued
    and monitoring is returned to the practice?

  • Where will our care manager sit/be located?

  • In which team meetings, huddles, or other team communication will our care manager participate?

  • What data systems will our care manager utilize to track progress?

  • Will our care manager be an employee of the practice, health system or other entity?

  • How will our care manager-patient visits be structured, like home visits versus in practice only, phone calls versus in person,
    joint visits with providers?

  • Will our care manager provide education only, assist patients with self-management goals, work with the patients’
    families/caregivers, call resources on behalf of patients, work on our disease registries, etc.?

By Complete Care Management, Inc.