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
"Boots on the ground" in all 100 counties
Care managers play a central role in helping the CCNC networks achieve its goals. They are primarily responsible for helping to identify patients with high risk conditions or needs, assisting the providers in disease management education and/or follow-up, helping patients coordinate their care or access needed services, and collecting data on process and outcome measures.
The CCNC Program Office recognizes the document Best Practices in Coordinated Care (Mathematica Policy Research) as an excellent reference for describing the key processes involved in the delivery of case and disease management services. A summary can be downloaded at right and the complete paper can be found on the Mathematica Policy Research website.
The CCNC Informatics Center in Raleigh provides each network access to a secure, web-based Care Management Information System (CMIS) for the management of its enrollees. The system includes modules for:
- Reporting (both individual and population level)
- Accessing claims data and other clinical and patient-centric data
- Case Assignment
- Patient Assessment and Care Planning
- Medication Management
- Secure Messaging System
The system can be used by all individuals that are either employed by, or are business associates of the CCNC, provided that each user is engaged in the process of patient care coordination only.
CCNC leadership and network representatives have ongoing planning sessions aimed at refining and improving the Care Manager’s ability to assess, plan, implement, and evaluate patient care management through CMIS.