Chronic Care and Preventative Care Management for Empaneled Patients

Activity ID

IA_PM_13

Activity Weighting

Medium

Subcategory Name

Population Management

Activity Description

Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:

• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;

• Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target; such as a CDC-recognized diabetes prevention program;

• Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions;

• Use panel support tools (registry functionality) to identify services due;

• Use predictive analytical models to predict risk, onset and progression of chronic diseases; or

• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.

Validation

Management of empaneled patients' chronic and preventive care needs (could use EHR or medical records)

Suggested Documentation

1) Individualized Plan of Care - Annual opportunity for development and/or adjustment of an individualized plan of care appropriate to age and health status; or
2) Condition-Specific Pathways - Use of condition-specific pathways for chronic conditions with evidence-based protocols, or
3) Pre-visit Planning - Use of pre-visit planning to optimize preventive care and team management; or
4) Panel Support Tools - Use of panel support tools to identify services that are due; or
5) Reminders and Outreach - Use of reminders and outreach to alert and educate patients about services due; or
6) Medication Reconciliation - Use of routine medication reconciliation

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