Embedding care management in the medical home: a case study

Area of Science:

• Primary Care Innovation
• Health Services Research
• Organizational Change Management

Background:

• Care managers are crucial in primary care redesign and patient-centered medical homes (PCMHs).
• Adoption and implementation strategies for care managers in daily practice are not well-documented.
• This study introduces a novel strategy for integrating care management into PCMH operations.

Purpose of the Study:

• To introduce a strategy for incorporating care management into PCMH operations.
• To assess the preliminary effectiveness of this care management implementation strategy.

Main Methods:

• A case study approach was used at the University of North Carolina at Chapel Hill Family Medicine Center.
• An organizational model of innovation implementation guided the study's parameters.
• Effectiveness was determined using data from the care management informatics system and electronic surveys from staff.

Main Results:

• Most physicians (75%) and staff (82%) interacted with care managers for referrals and resource assistance.
• A decrease of 8 emergency department visits per month was observed for care management recipients.
• An average of 7.5 inpatient admissions per month decreased during the initial 2-year implementation.

Conclusions:

• An organizational model for innovation implementation can effectively guide the integration of care management services.
• This approach supports the incorporation of care management into PCMH structures and workflows.
• Preliminary findings suggest a positive impact on healthcare utilization metrics.