Case managers embedded in Caldwell UNC Healthcare's seven primary care practices and two work sites measure productivity not by case load but by telephonic outreach. And in preliminary data, the program's average of one thousand "outreaches" each month has helped to halve 30-day hospital readmissions in its Medicare population, among other benefits.
Embedded Case Management in Primary Care and Workplace Clinics: Skill Sets, Stratification and Protocols documents Caldwell's outreach-focused embedded case management efforts, which are patterned on Geisinger Healthcare System's ProvenHealth Navigator℠ model.
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In this 25-page resource, Melanie Fox, developer and director of Caldwell Physician Network's Embedded Case Management program, outlines the origins and operations of the initiative, shaped by Ms. Fox's own background in home health. Observing patients' needs and family dynamics following discharge from hospital or SNF provided unique perspectives on care transition management that inform embedded case management, especially a focus on medication reconciliation.
Ms. Fox provides the following details:
- Skill sets for embedded case managers;
- Advantages of the embedded case management model;
- Dynamics of reporting to stratify individuals for case management outreach;
- Philosophy behind measurement of “outreach” rather than case loads;
- Outreach protocols and strategies;
- Impact of embedded case management on patient engagement and self-management;
- Inclusion of advanced illness management (AIM), or palliative care;
- Maximizing reimbursement for transitional care management;
- Impact of embedded case management on hospital readmissions;
- Goals and benefits of off-site health work clinics;
- Tactics for engaging physicians, staff and employers in the embedded model;
- and much more.
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