Implementing integrated, interdisciplinary clinical care management in patient-centered medical homes

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
November 23, 2013

Clinical care management (CCM) of the highest risk, most complex, and costly patients is an integral component of the patient-centered medical home (PCMH) but a new service for many primary care practices. The MA PCMH Initiative (MA PCMHI) is a 3-year, multi-payer demonstration with 45 participating practices. Support for CCM implementation is provided through learning collaboratives and practice facilitation. Techniques for shared learning include developing a CCM interdisciplinary team workflow utilizing process mapping and modeling care plan development. MA PCMHI practices have found these techniques valuable for clarifying what a care plan is and visualizing existing workflows, so others in the practice can more clearly understand the care manager role. Presenters will utilize these techniques with audience members to advance their knowledge and skill set in implementation of practice-based care management.

Center/Program: 
Office of Health Innovation & Quality
Conference Name: 
Conference on Practice Improvement, Society for Teachers of Family Medicine
Presentation Type: 
Workshop