Implementing an effective care management program requires planning and the right tools. The independent physician who sees a need to implement a comprehensive care management plan must first consider the factors involved for the practice as well as for the patients. Useful tools will enable the provider to then develop and maintain a care management plan that reduces costs, reduces or eliminates unnecessary visits and procedures, and provides a higher quality of care.
Useful care management tools include:
A pre-visit planning checklist
AAFP recommends this tool to “identify potential care gaps and otherwise better prepare for an upcoming patient appointment.” The checklist can be completed by a medical assistant or another member of the independent physician’s clinical staff who initially meets with the patient to gather a history and a list of additional healthcare providers treating the patient.
A patient-centered care plan
As described in an NEJM Catalyst article, a patient-centered care plan “encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan.”
Learn more about how Elation Health can help you develop your patient-centered care plan.
Records kept by the patient regarding exercise, food intake and voiding, and the timing and description of symptoms can aid the provider in determining the appropriate strategy and coordination of care. Patient diaries can become a valuable tool for an effective care management plan.
Electronic health records (EHRs)
Care management plans involve gathering, maintaining, and monitoring patient data. The EHR is a useful tool for the independent physician as well as for the patient. The NEJM Catalyst article details the need for technology, particularly when encouraging patients to fully participate in their own healthcare management. EHRs provide patients with “24/7 online portals that let patients schedule appointments, get information about their condition and care instructions, review lab results and doctor’s notes, and pay bills at their convenience.”
EHRs, such as Elation’s Clinical First solution, enable the provider to maintain a more comprehensive and longitudinal patient record. Independent physicians can take advantage of this useful care management tool to quickly identify patients who aren’t meeting goals based on custom care management protocols, Meaningful Use objectives, or specific document tags, and easily schedule a follow-up appointment to address any potential gaps in care.