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Social and Behavioral Sciences Commons

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Massachusetts

Commonwealth Medicine Publications

Family Medicine

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Full-Text Articles in Social and Behavioral Sciences

Implementing Integrated, Interdisciplinary Clinical Care Management In The Patient-Centered Medical Home, Jeanne Z. Cohen, Christine Johnson, Judith Steinberg, Sai Cherala Nov 2013

Implementing Integrated, Interdisciplinary Clinical Care Management In The Patient-Centered Medical Home, Jeanne Z. Cohen, Christine Johnson, Judith Steinberg, Sai Cherala

Commonwealth Medicine Publications

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 ...