Needs Statement:  

Care management programs are one of the foundational strategies used to advance value-based care. These programs focus on proactively identifying patients who are at high or rising risk and connecting them with resources to improve outcomes.  The success of these programs is contingent on the ongoing partnership and collaboration with the entire multidisciplinary team of clinicians and support staff.  This is because all value-based contracts are dependent on the performance of the network Physicians and APPs. However, oftentimes providers are unaware of these care management programs, and the care management teams are unaware of the provider needs. One of the key care management functions is to assist with transitions in care. Good transition of care begins at the time a patient is admitted to the hospital. It takes a coordinated care team to be successful in high quality care of our patients.

Learning Objectives: 

At the conclusion of the session, the participants should be able to:

• Define care management within Value Based Care.
• Describe the critical role of the CIN Care Management Team in coordinating care, improving patient outcomes, and supporting physicians and advanced practice professionals within a value-based care framework.
• Identify the specific criteria used for directing patients to the CIN Care Management Team.
• Review the role of the partnership between physicians, advanced practice professionals, and the care management team in enhancing patient care outcomes.
• Summarize the Hospital Readmission Reduction Program and identify best practices in reducing hospital readmissions.

Target Audience: 

This activity is intended for Physicians and Advanced Practice Professionals.

Educational Methods: 

Lecture