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RN Complex Care Manager (per 2,000 attributed lives) to coordinate episodic and longitudinal care management for rising- and high-risk patients, including:
- Identifying high-risk patients based on risk stratification and PCP referral
- Assessing the healthcare, educational and psychological needs of the patient/family
- Collaborating with PCP and other care team members to develop and monitor comprehensive individualized plans of care
- Providing patient education and self-management support
- Providing follow-up when patient transitions from one setting to another
- Uploading care alerts and care plans into CRISP
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Access to interdisciplinary team for consults on complex patient cases (e.g., pharmacy, dietician, social work, diabetes educator, respiratory therapy)
Pharmacist to conduct comprehensive medication management for rising- and high-risk patients, including:
- Assessing the patient’s medication therapy
- Developing and initiating an action plan to address risks and offer potential alternatives
Community Health Worker to provide support to rising- and high-risk patients, including:
- Assisting with patient activation and self-management support outside of the clinic
- Managing community-based social service referrals and follow-up
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