Implementing Integrated Clinical Care Management in the Patient-Centered Medical Home

Author: 

Jeanne Cohen

Jeanne
Cohen
M.S., R.N.
University of Massachusetts Medical School

Christine Johnson

Christine
Johnson
Ph.D.
University of Massachusetts Medical School

Judith Steinberg

Judith
Steinberg
M.D., M.P.H.
University of Massachusetts Medical School

Sai Cherala

Sai
Cherala
M.D., M.P.H.
University of Massachusetts Medical School
March 10, 2014

Clinical Care Management (CCM) of the highest risk, most complex and costly patients is a key element of the Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI), and is a new service for most primary care practices. There is much confusion about the role of the Care Manager (CM), and a lack of awareness of key foundational elements critical to successful implementation of CCM.  This poster describes the shared approach to implementation of CCM in the MA PCMHI, use of care management and care coordination clinical quality measures to monitor implementation progress, and shared lessons learned in the implementation process.

Center/Program: 
Center for Health Policy and Research
Conference Name: 
15th Annual International Summit on Improving Patient Care in the Office Practice and the Community
Presentation Type: 
Poster