Care Management Tools of the Trade

Explore the care management shared record, a patient-centered, unified data hub across care settings that streamlines workflow and meets payor requirements.

Improve patient care by coordinating records, referrals, and transitions across a multi-disciplinary team, supported by a unified patient registry and proactive population health management.

Coordinate care planning, medication lists, access to care, and quality improvement using the care management shared record to support patient self-management and goal-driven care.

Examine how the care management shared record aggregates information from multiple providers and settings to create a comprehensive continuum record that improves treatment and reduces errors.

Learn how telephonic and electronic outreach supports population management and preventive care by identifying gaps in care, using registries, and delivering evidence-based reminders.

Develop and implement systematic telephonic and electronic outreach to remind patients about preventive and chronic care, using reports and registries to coordinate pre-visit, during-visit, and post-visit tasks.

Enable telephone and electronic follow-up within 24–48 hours of hospital or emergency visits, coordinate referrals, provide self-management support, and remind patients about medications, labs, and no-show appointments.

The potential of telephonic and electronic outreach lies in a team-based care model, with trained staff delivering self-management support, reminders, and post-discharge follow-up to improve compliance and health records.

Identify who can be a caregiver and summarize common duties such as managing medications, coordinating care, and assisting with daily tasks. Understand why caregiver support strengthens the health care team.

Caregiver support centers on managing medications, reconciling prescriptions, monitoring side effects, and ensuring a current med list, one pharmacy, and communication with the office, pharmacy, and family.

Develop caregiver communication with health care professionals by preparing questions, tracking symptoms and medications, and using written instructions to ensure clear understanding during medical and behavioral health appointments.

Empower caregivers to navigate the healthcare system and coordinate care. Advance shared decision making with clear care plans, self-management tools, education, and resources.