Care management is the range of activities intended to improve patient care and reduce the need for medical services by helping patients and caregivers more effectively manage health conditions.
Keys to Care Management Success
- In-person encounters: Person-to-person encounters, including office visits, are necessary features of effective care management. Care management relying solely on telephone encounters has not shown success.
- Training and personnel: Programs with specially trained care managers who have a relatively low workload are most successful. Most care managers are registered nurses (RNs) who work as part of a multidisciplinary team.
- Care Manager involvement: Physicians refers a patient to care management who may help facilitate involvement.
- Informal caregivers: Patients with complex health care needs, particularly those with physical or cognitive functional decline, often need the assistance of informal caregivers to actively participate in care management.
- Coaching: Coaching involves teaching patients and their caregivers how to recognize early warning signs of worsening disease. Coaching also involves teaching patients to actively understand, manage, and coordinate their health. We help patients learn to be involved in their care.