1. Nurses, PHARMACISTS & Social Workers
PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT
Nurses, PHARMACISTS & Social Workers
16 Nurses and 3 Social Workers within RIPCPC have a presence in all 85 member offices
6 Pharmacists manage all Integra PCP offices
Collectively there are responsible for the 100,000+ lives Integra manages

2. Daily outreach report using a workbench reporting tool
PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT
Daily outreach report using a workbench reporting tool
NCM/Pharmacist/ Social Worker begins day by running report
Once a patient is reviewed, a Pt Outreach is opened.
The Care Manage: My outreach today report is run daily. The Nurse Care Manager or Pharmacist will use the report to help organize her day. The NCM is able to work from this report without having to leave the window. This window also gives a snapshot of information about the patient which includes hyperlinks to other contacts with the patient. Your patient outreach can be started right from this report.
All RIPCPC care managers add themselves to the care team, which drives reporting.

3. Patient outreach encounter
PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT
Patient outreach encounter
Call initiation section is completed and populates the patient’s care plan
The top grouping of the table of contents is the call initiation where the episode can be created, linked or updated. The staff add themselves to the care team and if they know other member they should add them as well.
Linking of encounter of episode
Care team drives relationship to patient for reporting

4. Problem oriented charting
PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT
Problem oriented charting
More than one problem list item can be charted on within the encounter.
Problem oriented charting is used for documentation. This allows the clinician to work with the patient and document as each problem is worked with the patient. This saves having to write narratives and relying on memory and cuts down on repetition.

5. Standardized note templates
PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT
Standardized note templates
Nurse Care Management Plan
is an contacted on
Reason for Outreach
Current Medications reviewed with patient:
Problem List Assessment and Plan:
Using a smart phrase allows the clinician to bring all the problem oriented documentation, the medication review and the goals into one cohesive and succinct note. This also allows reporting, because the staff all use this smart phrase to show a careplan has been created for the patient.

6. Pulling it all together
PCMH 4: CARE MANAGEMENT AND SUPPORT ELEMENT A: IDENTIFYING PATIENTS FOR CARE MANAGEMENT
Pulling it all together
The last piece of the care management visit is to track the patient outreach. This will close the loop, to update the outreach report.
Before closing the encounter, new tracking information is added for the patient.