Care management has been defined as “a set of activities designed to assist patients and their support systems in managing medical conditions more effectively. The goals of care management are to improve patients’ functional health status, enhance coordination of care, eliminate duplication of services, reduce the need for expensive medical services, and increase patient engagement in self care.”1 Care management is a team-based, patient-centered approach that has demonstrated potential to improve quality and control costs for patients with complex conditions.

Patient Assessment and Care Planning 

Interprofessional (IP) Student Learning Activity related to Care Management and Support (CM) Competencies A and B; and Knowing and Managing Your Patients (KM) Competencies A and D.

Learning Activity Overview

  • As an introduction to primary care-based interprofessional care, student teams will:
    • Work with the practice to identify a complex patient who would benefit from interprofessional care
    • Review the patient case as a team and conduct a mock pre-visit brief
  • Advanced: Student teams will conduct a comprehensive health assessment for a complex patient. Students will:
    • Participate in a team brief prior to engaging the patient
    • Conduct the adult comprehensive assessment
    • Debrief to reflect on team performance
  • Advanced: Student teams will interview and examine a patient. The visit may take place at the practice site, in the patient’s home, or another site deemed appropriate per practice protocol, and will include:
    • Identification of a complex patient and medical record review
    • A student team brief
    • A comprehensive health assessment, to include social determinants of health, or other focused assessment
    • A medication management review
    • Person-centered care planning
    • Presentation of the team’s assessment, recommendations, and care plan to the practice team
    • A student team debrief to reflect on team performance

Learning Objectives

  • Communicate information with patients, families, community members, and health team members in a form that is understandable, avoiding discipline-specific terminology when possible (CC2).
  • Engage diverse professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific health and healthcare needs of patients and populations (RR3).
  • Engage self and others to constructively manage disagreements about values, roles, goals, and actions that arise among health and other professionals and with patients, families, and community members (TT6).
  • Work in cooperation with those who receive care, those who provide care, and others who contribute to or support the delivery of prevention and health services and programs (VE5). 

(1: Goodell, S., Bodenheimer T. & Berry-Millet R. (2009). Care management of patients with complex health needs. The Synthesis Project, Policy Brief No. 19.)

Please see the full NCQA PCMH Standards (PDF) for important details these learning activities are based on.

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