Descriptions
Considers the following when establishing a systematic process and criteria for identifying patients who may benefit from care management (practice must include at least three in its criteria):
A. Behavioral health conditions.
B. High cost/high utilization.
C. Poorly controlled or complex conditions.
D. Social determinants of health.
E. Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff, patient/family/caregiver.
The practice defines a protocol to identify patients who may benefit from care management. Specific guidance includes the categories or conditions listed in A-E. Examples include, but are not limited to:
a. Diagnosis of a serious mental illness, psychiatric hospitalizations, substance use treatment.
b. Patients who experience multiple ER visits, hospital readmissions, high total cost of care, unusually high numbers of imaging or lab tests ordered, unusually high number of prescriptions, high-cost medications and number of secondary specialist referrals.
c. Patients with poorly controlled or complex conditions such as, continued abnormally high A1C or blood pressure results, consistent failure to meet treatment goals, multiple comorbid conditions.
d. Availability of resources such as food and transportation to meet daily needs; access to educational, economic and job opportunities; public saftey; social support; social norms and attitudes; exposure to crime, violence and social disorder; socioeconomic conditions; residential segregation (Healthy People 2020).
e. Direct identification of patients who might need care management such as, referrals made from health plans, practice staff, patient, family members, or caregivers.