If Taconic Professional Resources were to place a classified ad for an embedded case manager, it might look something like this:

Wanted: RN case managers with the motivation and personality to be change agents, collaborators and ambassadors of case management within physician practices.

The standards in this fictional ad reflect Taconic's faith in the co-located case management model. On the heels of its successful advanced medical home transformation, Taconic IPA has leveraged its experience with embedded case management to launch Taconic Professional Resources, an entity dedicated to the support, management, training and evaluation of case managers co-located in physician practices.

Advancing Primary Care with Embedded Case Management: Lessons from the Taconic IPA Pilot describes Taconic's commitment to embedded case management as well as the motivation behind the new entity and the case management-related services Taconic Professional Resources makes available to more than 5,000 physicians in its open, multi-payor environment.

Far from a staffing service, Taconic Professional Resources goes beyond the hiring of RN case managers to recruit, train and match case managers to individual physician practices in this Hudson Valley-based IPA, one of seven regional sites piloting CMS' Comprehensive Primary Care (CPC) model.

In this 25-page resource, Annette Watson, senior vice president of community transformation for Taconic, provides details on the following program concepts:

• Assessing physician practice needs and readiness for an embedded case manager;
• Framework of the Taconic embedded case management model;
• The varied roles of embedded case managers in physician practices, from supporting CPC to meeting accountable care organization (ACO) and patient-centered medical home (PCMH) requirements;
• Case management skill sets and domains, including patient empanelment and risk stratification;
• Funding strategies for an embedded case manager program;
• Patient referral sources and workflow strategies to maximize the embedded case manager function;
• Using electronic medical records, patient registries, payor data and other tools within a practice to support the embedded case manager;
• Taconic's trajectory from initial NCQA medical home recognition to the elevation of embedded case management to a separate enterprise;

Table of Contents

• Improving Population Health with Embedded Case Managers in an Open, Multi-Payor Community
  • Hudson Valley Transformation Trajectory
  • Advanced Patient-Centered Medical Home Pilot
  • Taconic Practice Transformation
  • Assessing Practice Readiness
  • Duties of Embedded Case Managers in Advanced Primary Care
  • Identifying High-Risk, High-Cost Patients for Case Management
  • Sample Risk Stratification Tool
  • Funding and Reimbursement
• Q&A: Ask the Expert
  • Background of Embedded Case Managers
  • 3 Challenges of Embedded Case Management
  • Contributions of Embedded Case Managers
  • Obtaining Physician Buy-In on Embedded Case Managers
  • Ongoing Training for Embedded Case Managers
  • Workflow Changes Supporting Embedded Case Management
  • Preferred Electronic Medical Records
  • Frequency of Patient Restratification
  • Home Visits by Case Managers
  • Challenges of Embedded Case Management
• Glossary
• For More Information
• About the Presenter