The people behind Community Care — and how we are improving health services in our state
A community-based infrastructure to target patients and populations in need
The processes and measurements behind our outcomes
Access to data to drive our success
New demonstrations, pilots and programs
Management ToolsPatient Management Tools
Patient Management Tools
Materials to support providers and help educate patients
The big picture plus a focus on individual patients
CCNC emphasizes population-based health management and quality improvement initiatives. CCNC networks are responsible for the delivery of care management services to selected patients that will improve quality of care while containing costs.
Although each network will develop its care management department based on knowledge of local resources and stake holders, the care coordination core processes are the same between networks. To assure consistency across networks, a "Standardized Care Management Plan" has been developed. The plan consists of a set of guidelines and standards for care management activities and reporting.
In summary, the plan provides for:
- Population Stratification, Case Identification, and Member Assignment -- The application of a common series of criteria and measures to the enrolled population to describe the distribution and severity of illness, and the index of resource utilization; assigning members to certain risk strata for care management, disease management and other preventive health programs.
- Member Care Coordination -- The provision of structured interventions to targeted groups in order to ameliorate bio-psycho-social risk factors and provide ongoing monitoring of the effectiveness of the care coordination effort.
Details on specific population management programs can be downloaded at right.