Primary care initiative program management office

Related Initiatives. Oklahoma Comprehensive Primary Care Initiative. Oregon Comprehensive Primary Care Initiative. Arkansas Comprehensive Primary Care Initiative.

Colorado Comprehensive Primary Care Initiative. Reported Outcomes. Program Website. May - News. March - News. October - News. June - News. April - Resource. April - News. Payment and Delivery System Reform in Medicare.

February - Resource. CPC mid-year snapshot. December - Resource. Primary care makes strides in improving quality and costs. October - Resource. September - News. July - News. Payment Model:. Shared Savings in Medicare Fee-for-Service: After two years, all practices participating in this initiative will have the opportunity to share in a portion of the total Medicare savings in their market. CMS Blog October results from first shared savings performance year All regions had lower-than-targeted hospital readmission rates.

Lower readmissions indicate better coordination of care during transitions and patient support during the post-discharge period. Improved Health:. Improved Access:. Cost Savings:. Other Outcomes:. Data Source s :. Learn about one LEAP site's approach to multidisciplinary case conference reviews, by looking at the care plan notes from one of these sessions for patients in the complex care management program. We're here to help. And if we can't answer your question, we can probably connect you with someone who can.

Level D generally does not occur because the information is not available to the primary care team. Level C occurs only if the ER or hospital alerts the primary care practice. Level B occurs because the primary care practice makes proactive efforts to identify patients. Level A is done routinely because the primary care practice has arrangements in place with the ER and hospital to both track these patients and ensure that follow-up is completed within a few days.

Clinical care management services for high-risk patients Level D are not available. Level C are provided by external care managers with limited connection to the practice. Level B are provided by external care managers who regularly communicate with the care team. Level A are systematically provided by the care manager functioning as a member of the practice team, regardless of location. What Do Your Choices Mean?

If you score in Level D in any area, your practice is just getting started and may want to review our resources page to help you prepare for the key changes described in that section of the guide. If you score in Level C in any area, your practice is in the early stages of change and can benefit from the action steps and resources in that section of the guide. If you score in Level B in any area, your practice has implemented basic changes and can build upon your success with the action steps and resources in that section of the guide.

If you scored in Level A in any area, your practice has achieved most or all of the important changes required. You can still use the actions steps and resources in that section of the guide to find new ways to improve. Care Management For chronically ill patients, proactive care management reduces the risk of complications and helps prevent costly hospital admissions and readmissions. Assess your practice Print Learning Module. Implementing Effective Clinical Care Management.

What needs to change? Primary care practices should try to establish a care management program with the following characteristics: RNs serve primarily as care managers complemented by social workers if available. Care managers are integrated with primary provider, team, and the Electronic Health Record. Proven strategies for identifying potentially appropriate patients. Trained nurses who can provide clinical monitoring, oversight of drug therapy, and self-management support.

Regular follow-up with patients that includes some face-to-face contact. Regular review of care-managed patients with clinical experts. What do we gain by making these changes? Think about care management as a program, not a person.

Role features. Care Coordinator Job Responsibilities. Attribution: St. Luke's Eastern Oregon Medical Associates. Terms of use. Nurse Care Manager Job Responsibilities. Health Coach Job Description. Attribution: Penobscot Community Health Care. Care Manager Job Description. Webinar and power point presentations. Models of Complex Care Management. Attribution: Center for Health Care Strategies.

Shift RN roles toward care management. Staff training. RN training materials. Decide which patients to refer to care management. Clinical protocol. Establish relationships with key hospital s to identify and co-manage patients discharged from the hospital. Attribution: Southeast Texas Medical Associates. Hospital Transition Overview. Create protocols, standing orders, and standard work flows. Care management discharge criteria.

Post-Emergency Department Follow-Up. Hospital Transition Intake. Transition Care Clinical Protocol. See protocol used by nurse care managers at one LEAP site for patient care transitions. High-Risk Case Management Overview. Make sure care managers have protected time to do their work. Develop a support structure for care managers. Case Conference Description. Complex Case Management Care Plan. Publications Publications. Attribution: The Commonwealth Fund. Toolkits Implementation guides and other documents with extensive resources included Toolkits.

Role features Job descriptions, career ladders and other HR materials Role features. Webinar and power point presentations Webinar and power point presentations. Staff training Tutorials, training manuals, etc. Clinical protocol Standing orders, risk stratification forms and hospital transition protocols Clinical protocol. Workflow Templates, flow sheets and mapping aids Workflow. Related Learning Modules View Topic. Assess Your Practice.

Improving Care Through Teamwork.