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.

Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness. This blog post was posted to AEA365 during a week of posts featuring the team at the University of Massachusetts Medical School that helped to evaluate the Massachusetts Patient-Centered Medical Home Initiative.

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.

Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness.

The Massachusetts Patient Centered Medical Home Initiative (MA PCMHI) is a statewide, multi-payer demonstration that seeks to transform 46 primary care practices into PCMHs. Clinical care management of high-risk patients is a key element of the PCMH and a new service for most primary care practices. Training for practices in the MA PCMHI includes the clinical care manager (CCM) role, identification/tracking of highest-risk patients, care plan development/implementation, care coordination, and communications. Content is delivered through learning collaborative sessions, monthly webinars and practice-based transformation facilitation. Assessment of progress towards implementation is made through practice-based data on clinical care management measures and self-assessment of transformation. At year one of implementation, averages for measures such as percentage of patients who received timely follow-up after hospitalizations and ED visits range 37%-63% with 35-40 of 46 practices reporting. The challenges that have hampered implementation include lack of: (1) EMR/registry functionality, (2) hospital to practice notification systems, (3) clarity of the CCM role and workflow, (4) risk stratification criteria for high-risk patients, and (5) adequate resources to support this service. An important lesson learned is that engaged leadership is critical to successful clinical care management implementation. Next steps include refinement of the practice-based self-assessment that is used as a monitoring and QI tool, and a pilot to study the coordination of payer-based and practice-based clinical care management.