Implementing Integrated Clinical Care Management in the Patient-Centered Medical Home

Abstract

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.