Care Management Jeraldine Stoltzfus, RN, BA Karen Woodruff, RN Vicki Rote, BA SW

1. October 28, 2010 Lincoln Family Medicine Strasburg Family Medicine Care ManagementJeraldine Stoltzfus, RN, BAKaren Woodruff, RNVicki Rote, BA SW

2. 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

5. Care Management Office Encounter Smart Text: LG CM ENC Intake Assessment and Care Plan

6. Intake/ Care Plan Paper Version Handout provided

7. Intake/ Care Plan Highlighted areas create Care Plan

8. Goals- specific and measurable

9. CHF Action Plan

10. CHF Action Plan

13. Care Management Collaboration • Patient Education • Disease education, Diet, and Activity • Blood sugar monitoring, BP monitoring • Newly diagnosed patient education • Insulin starts • Self Management Goals and monitoring progress • Programs- “Getting Through the Holidays” • Insurance, Financial and other concerns • Community Resources • Patient Empowerment

15. Care Management Documentation

16. .cmencounter

17. .cmhospital Daily Hospital Report Received

18. Community Connections • VNA • Horizon Infusion Services • LGH Diabetes and Nutrition Center • More to come

19. 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