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The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination
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In a new survey of healthcare organizations on the patient-centered medical home model, 60 percent of respondents include case managers on the medical home care team, with more than half of these respondents embedding these case managers within the primary care practice.

An early adopter of this trend is Geisinger Health Plan, whose placement of case managers inside selected primary care practices is paying off in better identification and management of high-risk individuals and improved quality indicators in areas such as medication compliance and hospital readmissions.

The Medical Home Case Manager: Profiting from Patient-Centered Care Coordination provides an inside look at the selection, training, skill set, processes and benefits of the Geisinger Health Plan case managers embedded within the payor's medical home practices.

Working within the ProvenHealth Navigator(SM) — Geisinger's home-grown medical home model — case managers are carefully matched with primary care practices, where they help the practice to identify its highest-risk population and develop customized care plans to guide those individuals to better self-management of their condition and more judicious use of healthcare resources.

How does the physical presence of a case manager in a physician practice affect practice design, processes, efficiency, patient health status, healthcare utilization and patient and provider satisfaction? In this 40-page resource, Diane Littlewood, R.N., and Joann Sciandra, R.N., both regional managers of case management for health services at Geisinger Health Plan, drill down to the specifics of the embedded case manager program, including:

  • Engaging and incenting physician practices to embed case managers to assist with care transitions and patient compliance;
  • The case manager selection and training process;
  • Identifying the patients that would benefit best from this type of case management;
  • Skill sets, roles, tools and responsibilities of the embedded case manager;
  • Case load management;
  • Real-life examples of patient self-management patient action plans;
  • Results from the Geisinger Health Plan's embedded case manager program, including its impact on patient compliance, care transition management, medication adherence, hospital readmissions and more; and
  • Planned expansion of the embedded care manager to other types of care sites.
Littlewood and Sciandra also provide detailed responses to questions on the embedded case manager model, including integrating the medical home case manager with health plan goals, participation in home health and home visits, building physician and staff buy-in for the process and the price tag and time lines for medical home infrastructure.

This exclusive report also summarizes the responses of 187 healthcare organizations to HIN's December 2009 Industry Survey on Healthcare Case Management, including details on prevalence and targets of healthcare case management, roles and responsibilities of today's healthcare case manager, and results and ROI from case management efforts.

Table of Contents

  • Geisinger ProvenHealth Navigator: Payoffs of Placing Case Managers in Primary Care
      The Embedded Case Manager
    • Principles and Priorities of Case Management
    • Selecting a Case Manager
    • Case Manager Skill Sets
    • Case Manager Training and Support
    • Identifying High-Risk Cases
    • Post-Discharge Processes
    • Results from the Case Manager Effort
  • Q&A: Ask the Experts
    • Integrating the Medical Home with the Health Plan
    • Technology Supporting the Medical Home Model
    • Staffing the Case Manager Call Center
    • Home Health and Home Visits
    • Stratifying Complex Patients
    • Case Manager Competencies
    • Investment in Medical Home Infrastructure
    • Targeted Case Management Populations
    • The Case Managers Role in the Practice
    • Engaging the Practice in the Program
    • Making the Most of the Case Manager Resource
    • Case-Managing the Most at Risk
    • Building Physician Buy-In for the Embedded Case Manager
    • Case Management Tools
    • Predictive Modeling for Risk Identification
    • Funding and Reimbursement for the Embedded Case Manager
    • Timeline for Program Implementation
    • Importance of Technology in Program Model
  • Glossary
  • For More Information
  • About the Presenters
Publication Date: April 2010
Number of Pages: 40
ISBN 10: 1-936186-17-9 (Print version); 1-936186-18-7 (PDF version)
ISBN 13: 978-1-936186-17-4 (Print version); 978-1-936186-18-1 (PDF version)
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