Interprofessional teams of students participating in the Care Management Learning Activities visit and examine a patient with a complex condition, conduct a comprehensive health assessment, complete a medication management review, write a draft report and present their overall assessment and draft recommendations to the practice team.
The overall patient goals are to: assist patients and their family/caregivers in managing the patient’s conditions; improve the patient’s health care; and reduce health costs.
This interprofessional student learning activity is intended to help a practice meet the following NCQA Patient Centered Medical Home (PCMH) recognition standards: Standard 3 Element C; Standard 4 Element A; Standard 4 Element B; and Standard 4 Element C.
Organization of Care Management Learning Activities
- Interprofessional Student Teams. The interprofessional student team comes together to learn from, with and about each other.
- Patient Identified. Using criteria established by the practice in Standard 4 Element A, Identifying Patients for Care Management, an appropriate patient is identified for the student team to provide care management activities with.
- Patient Encounter. The student team interviews and examines a patient, involving the family/caregivers as is appropriate and using care planning strategies found in Standard 4 Element B, Care Planning and Self-Care Support.
- Comprehensive Health Assessment. The team completes a comprehensive health assessment using the factors in Standard 3 Element C, Comprehensive Health Assessment.
- Medication Management Review. The team conducts a medication management review to meet Standard 4 Element C, Medication Management.
- Report and Presentation. The team writes and presents their overall assessment, recommendations and patient care plan to the practice team. This presentation may or may not include the patient and/or family/caregivers.
Background on Care Management
According to NCQA, care management is a “collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet the comprehensive medical, behavioral health and psychosocial needs of an individual and the individual’s family, while promoting quality and cost-effective outcomes. The goal of care management is to help patients regain optimum health or improved functional capability, cost-effectively and in the right setting. It involves comprehensive assessment of the patient’s condition; determining benefits and resources; and developing and implementing a care management plan that includes performance goals, monitoring and follow-up.”