Effective Care Management Strategies for Chronic Diseases
Explore a week in the life of care management, starting with an overview of where to begin and a focus on chronic diseases. Discover a comprehensive approach including patient follow-up calls, medication reconciliation, care coordination, and more to provide optimal care for patients with multiple chronic illnesses.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
You are allowed to download the files provided on this website for personal or commercial use, subject to the condition that they are used lawfully. All files are the property of their respective owners.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author.
E N D
Presentation Transcript
A Week in the Life Getting started with Care Managment
Where do you start?
Something for everyone! Chronic Disease Newly Diagnosed Gaps in Care Not at Target Transition Management Counseling Referrals Education Disease specific Specialty Care Obesity/BMI LDL/Cholesterol BP/HTN A1C/Diabetes Multiple Co-Morbidities ER Follow-Up Post Hospitalization MA ? Who
Monday Tuesday Wednesday Thursday Friday 8:00 AM - 9:00 AM Weekly Clinic Team Meeting- review weekly schedule; high risk patients, patient care updates Huddle/Team Conferences Huddle/Team Care Conferences On high- risk patients Review Cases for Upcoming Week: Create schedule of patients who would benefit and discuss with provider. GAPS report Provider Schedule Review Cases for Upcoming Week: Create schedule of patients who would benefit and discuss with provider. GAPS report Provider Schedule 9:00 AM - 12:00 PM: Patient Follow- Up Calls ADT List for TOC Calls Call High Risk patients tucked in for the weekend Patient Follow- Up Calls ADT List for TOC Calls Patient Follow-Up Calls ADT List for TOC Calls Patient Follow-Up Calls ADT List for TOC Calls Patient Follow-Up Calls ADT List for TOC Calls Case Finding Assessment Medication Reconciliation Review medication lists for patients scheduled for upcoming visits, reconciling any discrepancies and ensuring they align with treatment plans. Medication Reconciliation Review medication lists for patients scheduled for upcoming visits, reconciling any discrepancies and ensuring they align with treatment plans. Medication Reconciliation Review medication lists for patients scheduled for upcoming visits, reconciling any discrepancies and ensuring they align with treatment plans. Medication Reconciliation Review medication lists for patients scheduled for upcoming visits, reconciling any discrepancies and ensuring they align with treatment plans. Medication Reconciliation Review medication lists for patients scheduled for upcoming visits, reconciling any discrepancies and ensuring they align with treatment plans. Care Coordination Care Coordination Care Coordination Care Coordination Care Coordination Work with a patient diagnosed with multiple chronic illnesses to Work with a patient diagnosed with multiple chronic illnesses to coordinate care among Work with a patient diagnosed with multiple chronic illnesses to coordinate care among different Work with a patient diagnosed with multiple chronic illnesses to coordinate care among different Work with a patient diagnosed with multiple chronic illnesses to coordinate care among different
