Care Management Toolkit
New Care Management Toolkit
The care management programs available to The Physician Alliance providers and patients provide important opportunities to improve patient care, and practice quality metrics and revenue. TPA created a Care Management Toolkit to help support practices in population health outcomes by offering a patient-centered approach for care management.
Along with using electronic medical records to identify affected patients to initiate outreach, practices can utilize the following resources to engage patients withbehavioral and chronic conditions, including addressing social determinants of health.
Patient education materials:
- Behavioral health care management poster
- Care management services poster
- Practice tips: The importance of scheduling 7-day post-discharge appointments flyer
- Tips to avoid another hospital stay – for patients flyer
- Transitional care management payor coding tip sheet
- Medication reconciliation post-discharge tip sheet
- Tips for lowering & taking blood pressure pad (with patient tracking sheet)handout
- “Ask us first” urgent care poster
- Urgent care handout (customizable form for practice contact info and recommended urgent care facilities)
- Social media graphics
Many of these resources can be accessed through TPA’s secure member portal, available to providers participating in TPA’s PGIP group.
Additional care management resources:
- To help remove some barriers to needed care and link patients to community resources, TPA PGIP practices can utilize the Community Health Services toolkit in coordinating care. View this toolkit here.
- TPA PGIP practices can submit a request for TPA’s community health worker to contact patients in need of non-medical resources (walker, baby formula, transportation, etc.) – access this free service in the member portal [LINK].
- Practices can help align diabetic patients’ health goals by accessing TPA’s diabetes toolkit, which includes resources and materials on diabetes management, and patient self-management/action forms to help control and lower risks of diabetes.
- The Physician Alliance has also partnered with Gap Healthcare Solutions to aid private primary care practices with their Provider Delivered Care Management (PDCM) delivery. Gap Healthcare Solutions can help improve patient outcomes and reduce administrative burden by providing a focused suite of care management services. View flyer here and video here.
- Private practices interested in support for the BCBSM Psychiatric Collaborative Care Model (CoCM) for their patients can work with Janus Healthcare Partners (TPA’s partner) to provide turnkey collaborative care services. To learn more about understanding new CoCM VBR opportunities, view video.