Getting started with care management – important things to be done
on the way to care management success

<Identifying patients for care management>
Care management can be an intensive and costly process and is not necessary for all patients. Identifying patients who can benefit the most from care management is key for the success of your program. For some practices, payers will be determining which patients to target for care management, or the hospital system or organization may determine patients to receive care management services. There are also some predictive models a practice can use to determine which patients to target for care management. However, care managers often work with patients by finding them in two ways:

1. Patients fit into a bucket of services that care managers look for and reach out to so they can engage the patient in care.
2. Providers or other staff in the practice identify a patient with a need in which care manager services may benefit and refer the patient to the care manager.
For approach 1, care managers are often looking for patients to reach out to. A very common bucket of patients who may be reached out to are those who are transitioning from care settings. The care manager (or other staff member) may look through the list of hospital discharges or ER visits to identify patients in the practice.

S/he may then look for patients with certain types of conditions in which follow-up after discharge is needed. Care managers also often look for patients who are potentially over-utilizing services, such as visiting the ED instead of the practice for care that could be provided in the practice.
Another key way that care managers reach out to patients for care is when they are out of range for certain desired clinical values. For example, care managers may comb through the EMR and use the registry function to identify diabetic patients who have not had a visit in the past six months and whose clinical values (A1c, blood pressure, lipids, etc.) are out of recommended range. The care manager may reach out to the patient to have the patient visit the doctor and then the care manager. Care managers and other staff may contact patients to recommend that they complete preventive care as well, such as assisting them in scheduling a mammogram or colon cancer testing.
In addition to care managers proactively finding patients who may need additional care, the care manager provides an important role in helping facilitate additional care of patients who are being seen for a visit at the practice or in which the patient or caregiver has initiated care. This usually falls into the category of the patient being out of range on clinical values, but usually is the result of social needs that make it difficult for the patient to meet his or her health goals. This includes issues of difficulty paying for medications, transportation problems, getting enrolled in services and plans such as Medicaid, and other health and safety issues. Good sources of information and referral for patients being seen by the provider that day include the huddle, the Medical Assistant rooming the patient, and the receptionist. Some care managers make home visits to assess the home environment and educate patients. Many times, however, care managers work with patients during visits to the practice or through phone calls.

<Determining workflows for care management>
An important part of the planning and learning your practice will do about care management is to determine the workflow of care management. As we mentioned above, there may be different ways that patients are identified and are referred to the care manager, so you will likely need multiple workflows for the different scenarios. This section lists some important questions in determining the workflows for the different type of work. We also provide examples in the appendix (page 106) of possible care manager workflows.

Here is a list of questions to ask in determining the care management workflow:
• How are patients identified for care management? Who identifies the patient?

• Once the patient is identified, how is the referral made to the care manager? Who is involved in this process? Where will care management services be provided?
• What happens during the care management visit? What is the usual length of the visit? How is this communicated to the rest of the care team members?
• What happens with patient follow-up? How is this communicated?
If workflow concerns arise, consider using the quality improvement steps described earlier in this section.

By Complete Care Management, Inc.