Patient Identified

The practice should use the factors established in Standard 4, Element A, Identify Patients for Care Management in order to choose patients with modifiable risks for the interprofessional team of students to conduct the care management learning activities with.

Some examples of criteria for eligible patients include those with:

  • Behavioral health conditions (Factor 1)
  • High cost/high utilization (Factor 2)
  • Poorly controlled or complex conditions (Factor 3)
  • Social determinants of health (Factor 4)
  • Referrals from outside organizations (Factor 5)

Some specific examples include:

  • Patients with opioid addiction (>100 mg equivalents of morphine per day) with chronic non-cancer pain (Factor 1)
  • Complex patients (e.g., with 2 or more major chronic conditions and 5 or more prescriptions) who have recently been discharged from the hospital with evidence of instability (e.g., Hgb A1c  >9%), who are dually eligible for Medicaid and Medicare insurances (Factors 2, 3, 4)
  • Families of newborns living in poverty and/or with teenage parents (Factor 4)
  • Patients referred by social services (Factor 5)

Patients should be chosen who are appropriate for the student team. For instance, if a dental student is on the team, then a patient with health problems that include oral health or a strong connection to oral health should be chosen. 

The patient or family/caregivers will need to be contacted before the student team visit, since home visits may not be able to accommodate a student team, and an office visit with a team may take longer than the patient expects from a normal office visit.