Care Coordination
The primary goal of care management in the ambulatory setting?
What is to educate patients to care for their chronic disease
This is reviewed with every TCM call.
What is medication reconcilliation.
These people cover your PTO.
What is buddy group.
This is an EPIC tool that is secure to communicate patient needs.
What is Epic secure chat.
Scheduling visits through Epic triggers this survey to patients.
What is Press Ganey.
A tool that the team can use to identify potential patient that would benefit from care management.
What is the Wellness registry
This is the billing code use for med recon.
What is 1111F
Home health and hospice referrals can be handled by this centralized team.
What is ASA's.
This format is used to discuss concerns or possible changes to workflow.
What is SBAR.
These are the four high-risk diagnosis.
What is COPD, CHF, DM and pneumonia.
ACN can ensure that a follow up patient meets the ACM.
What is schedule appointment with ACM at PCP follow up appointment.
This is what happens to patient assistance medications that the patient does not pick up.
What is disposal.
This is a way to show appreciation to a teammate within the Bronson System.
What is Awardco.
This is an interdisciplinary team conversation used to discuss plan of care for patients.
What is Team Conference.
These are the team members that can provide a second touch for incentive programs.
What is ACM, ACN, MSW, PharmD
The goal of weekly high-risk follow-up calls.
What is decrease readmissions.
Patient assistance medication is documented in two places.
What is medication logbook and EPIC
This is a communication tools used by the team to inquire or share information.
What is Team's chat.
The ACN notifies the PCP or ACM on issues for follow-up utilizing this.
What is the in-basket message
This is the target for patients HgbA1c
What is less than 7
The members of the CCM care team.
What is ACM, PCP, MSW, PharmD
Patient assistance medications are logged by these team members.
What is ACM, PharmD, and MA's
This is a confidential way to provide yearly feedback on team members.
What is peer review.
PTO requests are sent to these two email groups.
What is ACM Supervisor and CDACM.
TOC calls within 1-3 business days help to prevent this.
What is hospital readmissions.