Team development Interdisciplinary team development requires dedicated, coordinated work. How a team operates relates to its institutional location and structure. These can range from primary care, clinic-based comprehensive interdisciplinary teams…
All programs had to apply the CMS demonstration-wide eligibility criteria for participating beneficiaries who were enrolled in Medicare Parts A and B, had Medicare as primary payer, and not enrolled…
Guided Care, however, was designed to enhance primary care by infusing the operative principles of all seven chronic care innovations outlined in Table 10.1. Thus, Guided Care seeks to make…
Resources A collection of resources, often referred to as the depression “toolkit,” was assembled for use in the HRC Depression Support Service. Depression screening During the initial rollout of the…
The population screen shows each client’s name, risk score, gender, and counts of key events including: (1) Episodes – key risk areas, (2) Claims – total claims, (3) Office –…
–> Background On most surveys of general health status, residents of Mississippi rank at or very near the bottom (United Health Foundation 2009; The Commonwealth Fund 2009). In NMMCI’s service…
Outline care plan, including interventions and recommendations. Allow electronic access by CC, PCP, and/or other specialists. Provide printable format for care conferences and appointments. Patient Summary Sheet Provide printable format…
One of the primary discoveries we made was that clinics already had many of these functions, and that IT use could be successfully enhanced through addition of a small set…
Targeting the right population with the right services The ICM model is designed to provide specialized care management services to two larger groups of individuals that fall into complementary subdivisions…
Areas of focus The target population of the I-PiCC pilot was high-risk, high-cost elderly individuals living in the community with multiple co-morbid conditions who would benefit from greater PCP integration…
