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Pay For Performance

Individual Care Management Initiative

PCMH Capability 4.0

 

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Goal

· Implement individual care management capabilities among practices to ensure appropriate and effective chronic disease management empowering patients to take greater responsibility for their health;

· Focus on diabetes care demonstrating improved outcomes, processes and patient satisfaction measures;

· Establish procedures for self-management, goal-setting with patients with chronic conditions; and

· Implement educational tools to be used with patients.

 

Objective

· To increase practice chronic disease management activities for all JPA practices.

 

Practices should

1. Review the Individual Care Management Initiative with JPA’s Quality Management Coordinator focusing on any gaps in service; and

2. Develop procedures for planned visits, action plan development and self-management goal setting for patients with diabetes.

 

Resources

 

· Chronic Care Model

· Group Visits

· PCMH Planned Care

· Planned Visits

· Self Management Support Training Materials

· Team Care

· TransforMed

· 2011 Initiative Plan

 

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Core Clinical Process-Focused Initiatives