care management jeraldine stoltzfus, rn, ba karen woodruff, rn vicki rote, ba sw
DESCRIPTION
October 28, 2010. Lincoln Family Medicine Strasburg Family Medicine. Care Management Jeraldine Stoltzfus, RN, BA Karen Woodruff, RN Vicki Rote, BA SW. Care Management Registry Population Identification. Risk Stratification Reports Newly Diagnosed Patients Disease specific reporting - PowerPoint PPT PresentationTRANSCRIPT
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