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One can collaborate with local community organizations to create interventions that address gaps in patient care. Encourage patients to take part in community health programs that can help them manage or improve their condition or disease.
Fremont, CA: Care management is a comprehensive set of services and activities that help patients with chronic or complex conditions manage their health. The overarching goal of care management is to improve patient health. In order to get there, the model intends to improve care coordination, reduce hospital visits, and increase patient engagement. Care management software can greatly assist healthcare providers in meeting these objectives.
Comprehensive care management necessitates collaboration. Physicians, clinicians, patients, and caregivers must all collaborate to assist patients in taking control of their complex health needs.
Launching a care management program needs the following components:
• Value-driven Care: Comprehensive care management fits well into a value-based care model due to its emphasis on improving outcomes and reducing total health care costs.
This model allows healthcare organizations and certain providers to bill the Centers for Medicare & Medicaid Services (CMS) for care management services. CMS refers to this program as Chronic Care Management (CCM).
• Community Resource: One can collaborate with local community organizations to create interventions that address gaps in patient care. Encourage patients to take part in community health programs that can help them manage or improve their condition or disease.
• Coordinating Care: One should organize dedicated care teams for patients with severe and complex conditions that communicate and collaborate on patient assessments, interventions,
• treatment, and care planning on a regular basis. All members of the care team should have clearly defined roles. This level of care coordination necessitates the implementation of systems and strategies to reduce duplication of services.
• Data collection, Analytics, and Integration: Data can be extracted and aggregated from patients' electronic health records (EHRs), claims data, as well as other sources. One should use analytics software to sort through relevant data in order to determine patients who could benefit the most from care management, such as those with chronic diseases or at high risk.