care management jeraldine stoltzfus, rn, ba karen woodruff, rn vicki rote, ba sw

Care Management

Jeraldine Stoltzfus, RN, BAKaren Woodruff, RNVicki Rote, BA SW

October 28, 2010

Lincoln Family MedicineStrasburg Family Medicine

Care Management RegistryPopulation Identification

•Risk Stratification Reports

•Newly Diagnosed Patients

•Disease specific reporting

•Hospital Admission and ER reports

•Physician Referrals

•Insurance notification of High Risk Patients

Care Management Office Encounter

Smart Text: LG CM ENCIntake Assessment and Care Plan

Intake/ Care Plan Paper Version

Handout provided

Intake/ Care Plan

Highlighted areas create Care Plan

Goals- specific and measurable

CHF Action Plan

CHF Action Plan

Care Management Collaboration

•Patient EducationDisease education, Diet, and Activity Blood sugar monitoring, BP monitoringNewly diagnosed patient educationInsulin starts

•Self Management Goals and monitoring progress•Programs- “Getting Through the Holidays”•Insurance, Financial and other concerns•Community Resources•Patient Empowerment

Care Management Documentation

.cmencounter

Daily Hospital Report Received

.cmhospital

Community Connections

•VNA•Horizon Infusion Services•LGH Diabetes and Nutrition Center•More to come

Measurement

•Care Manager telephone encounters•Care Management visit encounters•Patient Satisfaction Survey- Baseline and Annually•Hospital/ER utilization•Readmission Rates•Patient outcomes•Patient progress with self management goals