Provider Insider

Care Management Insights

Spring 2019 | Issue No. 5

Care Management in value-based health care


Value-based models of care are intended to deliver better health outcomes than traditional fee-for-service models, and at a lower cost. Effective care management plays a critical role in delivering on those results. But how is this service different from what providers have been offering all along?



Providing ambulatory care management


A care manager’s primary function is to identify any barriers that will prevent a patient from successfully following his or her physician’s prescribed care plan, and offer the appropriate interventions to neutralize those barriers. These interventions could include education around disease management or behavioral health, connection with community resources, coordination of medical services or appointments among different providers, emotional support and more.


Care management often begins with a transition of care, e.g., an inpatient or acute hospitalization, emergency department (ED) visit, discharge from a post-acute facility or an inpatient behavioral health facility. Or a care manager may become involved when a patient has been identified as high-risk or high-complexity.


Registered nurses, social workers, licensed practical nurses and medical assistants are among those who comprise the care managers represented within Coordinated Care. In some cases, these individuals are centralized supporting a group of providers and/or clinics, in others they are embedded in-clinic as an integral part of the care team.


One thing they all have in common is the support service they provide across the entire care continuum.


In a traditional fee-for-service model of care, patients are often left alone to navigate the health system. And many, for one reason or another, fail to execute their care plan. Care managers help close that gap by providing patients tools and education to successfully self-manage their care plan. And, if all options are exhausted and a change in plan is required, care managers work collaboratively with providers to help patients find an alternative solution.


This level of care helps patients, many with complex medical conditions, better manage their health—potentially preventing unnecessary doctor and/or ED visits which in turn increases patient satisfaction and reduces the financial burden to the patient and health care system.



The CIN difference


The Population Health Service Organization (PHSO) has developed comprehensive assessments for Coordinated Care to standardize workflows for the network’s care managers. These assessments are functional tools to help our teams identify barriers in care and recommend the appropriate resources or interventions to allow patients to better self-manage their own health.


Assessments include:

  • Inpatient Transitions of Care
  • ED Follow-Up
  • Care Management assessment
  • Social Work assessment

Each of these assessments are available in Epic. Users can find Inpatient Transitions of Care and ED follow-up assessments through the Patient Outreach encounter, and authorized users can find all five assessments in the Care Management or Social Work encounters.


Any notes or work saved to these assessments is communicated in real time and is available to the entire care team on the Encounters tab. This process ensures proper documentation and helps streamline patient care and communication.


For questions about care management or the PHSO assessments available to Coordinated Care, please contact [email protected].