Population Management

CCNC Care Management

An analysis of CCNC's care management program

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Care Management

"Boots on the ground" in all 100 counties

CCNC Care Management (CM) is a set of interventions and activities that address the health care of a population to promote quality, cost-effective care. CCNC CM programs apply systems and information to improve care and assist patients to become engaged in a collaborative process designed to manage medical, social and behavioral health conditions more effectively and improve outcomes. CCNC views the term “care management” as an umbrella term to include case management, care coordination and targeted care management.

The CCNC Care Management model is evidence-based and built on frameworks, standards of practice and quality guidelines from nationally recognized models and industry leaders, including:

  • Chronic Care Model
  • Case Management Society of America (CMSA)
  • Commission for Case Manager Certification (CCMC)
  • National Committee for Quality Assurance (NCQA)

Goals of NCCCN Care Management

  • Maintain a model that focuses on patient engagement, empowerment, and education
  • Using an interdisciplinary team, meet the needs of chronically ill members by reducing their vulnerability and changing the trajectory of the course of their chronic illness
  • Work with medical homes to promote treatment regimens that are aligned with evidence-based guidelines
  • Help medical homes design workflows that are patient-centered and focus on facilitation of behavior change and self-care while addressing emotional and social issues as well.
  • Reduce fragmented care and facilitate communication across settings and providers

In order to effectively and efficiently meet the complex needs of high-risk patients and to provide the optimal benefit, CCNC's CM program is operated as a team approach under the oversight of the Primary Care Manager and in collaboration with the Primary Care Physician. The Primary Care Manager (PCM) may be a registered nurse (RN), social worker (Bachelors or Masters prepared), or Certified Case Manager (CCM), and coordinates and oversees the delivery of care management services to each patient on their case load. Since PCMs from various disciplines are utilized, the needs of individual patients are aligned with the specific scope of practice, education and expertise of the PCM (e.g., RNs manage more medically complex patients while social workers may work with patients with behavioral health and/or psychosocial conditions). In addition to RNs and Social Workers, the interdisciplinary team may also include pharmacists, pharmacy assistants, nutritionists, experts in behavioral health, palliative care, community resources, care management assistants, etc. The staffing model is designed to enable an efficient workflow and allow professionals to work at the top of their license.