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.

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 Massachusetts Patient-Centered Medical Home 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. Presented at the Conference on Practice Improvement Society for Teachers of Family Medicine.