02 — Capability · BC-1860.20
Care Management Programs
Help people with complex, chronic or transitional needs stay well between visits, by enrolling them in care, disease and transition programs, assigning a care manager and following a shared plan with them. Care planning inside a visit or stay is clinical care delivery.
- Care Management
- Disease Management
- Complex Case Management
- Payer Case Management
In scope
- Program intake and outreach to eligible people
- Care manager assessments, goals and longitudinal care plans
- Follow-up after hospital and facility discharge
- Caseloads and program outcomes
Out of scope
- Care planning and coordination within an episode of care (see BC-1820.30)
- Discharge planning and bed flow (see BC-1820.50)
- Remote monitoring and virtual visits (see BC-1820.60)
- Utilization review of requested services (see BC-1870.50)
Realized by · 6
- Salesforce · Health Cloudpartial via BC-1860.20.20
- Epic · Healthy Planetstrong via BC-1860.20.30
- Oracle Health · Health Data Intelligencestrong via BC-1860.20.20
- InterSystems HealthShare · Event Notificationsstrong via BC-1860.20.40
- InterSystems HealthShare · Care Communitypartial via BC-1860.20.30
- HealthEdge · Clinical Edge Care Managementcore via BC-1860.20.10
Used in · 1
Build it · 0
- Nothing in the library points here yet.
Decomposes into · 5
- BC-1860.20.10Care Management IntakeInvite people who qualify into the right program, record their consent, and keep trying to reach those not yet engaged.
- BC-1860.20.20Care Manager AssessmentAssess each enrolled person's health, daily function and social situation, and agree goals with them and their family.
- BC-1860.20.30Longitudinal Care PlansKeep one shared plan across settings and clinicians that records goals, actions and owners, and update it as needs change.
- BC-1860.20.40Transitions of Care Follow-UpContact people soon after a hospital or facility discharge, confirm what changed and arrange follow-up, so avoidable readmissions are prevented.
- BC-1860.20.50Caseload & Program OutcomesBalance caseloads across care managers, track contacts and goals, and measure whether each program improves outcomes and cost.