Implementation of Care Management: An Analysis of Recent AHRQ Research

Abstract

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

Importance of Geriatric Syndrome Screening within 48 Hours of Hospitalization for Identifying Readmission Risk: A Retrospective Study in an Acute-Care Hospital

“…31 ) Furthermore, EHRs facilitate communication among medical staff and organizations and provide structured coordination and documentation of the medical services provided. 32 ) Therefore, GSC performed within 48 hours of hospitalization using the EHRs of all inpatients aged 65 years or older is expected to be efficient.…”

Exploring family needs in neonatal and pediatric intensive care units at King Khaled Hospital- Jeddah

“…The differences in family need perceptions among the three groups of study participants also existed in "helping with the patient care" (p=0.009), shown in Table 5. The value of this family need of Saudi parents should be valued more since the role of the family members care providers is widely accepted [38] and requires continuous support.…”

Organizational Conditions That Impact the Implementation of Effective Team-Based Models for the Treatment of Diabetes for Low Income Patients—A Scoping Review

“…Methodologically, these studies were principally qualitative ( 7 , 35 – 38 , 40 , 41 , 44 , 47 , 49 , 51 , 54 – 56 ), with a few using mixed methods ( 6 , 39 , 42 , 45 , 48 , 50 , 53 ) and two randomized control trials ( 28 , 46 ). Furthermore, two reviews ( 24 , 52 ) were included about diabetes that provided some insights into the organizational context necessary for team-based care, although they were not specifically about organizational conditions.…”

“…At a macro-level studies identified organizational factors focused on the capacity to exchange clinical and billing data across providers to improve coordination. Significant attention is also provided to the role of technology at the meso level including access to an electronic medical record (EMR), a data manager, technical resources, data analytics capacity, patient registries, hospital admissions data, compliance, and quality metrics ( 6 , 7 , 24 , 28 , 38 , 46 , 47 , 49 , 52 , 55 , 56 ). At the micro-level a U.S. Agency for Healthcare Research and Quality review ( 59 ) on the implementation of its diabetes care models provides significant guidance related to technology supports for the team citing EMRs and IT that enable and support “communication among care team members (e.g., via electronic patient care plans); managing patient registries; coordinating, and documenting services to be delivered in a structured manner; reminding patients about appointments or contacting patients who were lost to follow-up; creating and tracking patients' plans of care and progress toward their goals; identifying additional “triggers”.” Further research needs to be carried out in low income settings countries and communities with low income patients.…”