What is the next secret ingredient for Care Management?
December 8th, 2016 | Clinical ConnectionsBy Daryl Sharp
AHP’s care management team has expanded and diversified over the past two years to include nurse care managers, social workers, and data coordinators as well as our pharmacist, practice facilitator, staff development coordinator and clinical integration specialist. The team is focused on three key areas: 1) closing gaps in quality metrics that improve patients’ outcomes and experiences of care as well as open gates to gainsharing; 2) coordinating care for those with multiple chronic or complex conditions who are at the highest risk for clinical decline and/or avoidable hospital use; and 3) transition management to ensure continuity of care as patients move across the health care system, especially post-hospitalization, ED and/or rehabilitation use.
Ongoing education, training and mentoring have been integral to our team’s success. In addition to completing an online care management education course, team members participate in monthly learning collaboratives that have been established throughout the network in which evidence-based care protocols and best clinical practices including fidelity guidelines are discussed and disseminated.
In the forthcoming year, we expect to focus on expanding the team’s behavioral health integration knowledge and skills to more effectively meet the needs of patients who along with chronic medical conditions are living with anxiety, depression, substance use disorders and/or the sequelae of trauma. Our 2nd annual AHP care management summit on December 8th will provide a forum in which staff across the network will not only learn about key AHP initiatives but also will work with behavioral health experts to strengthen delivery of evidence-based problem-solving interventions in primary care.
If you have questions about or would like to discuss care management, please email me at [email protected].
