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[null,"The Value of Care Management"]
[null,null,"Care management is an ambulatory practice strategy to improve patient and provider experiences while decreasing costs.1  Care management activities are intended to improve coordination of care while providing cost effective, non-duplicative services.  These services ultimately help patients manage their health conditions more effectively.2"]
[null,null,"Coordinating care for high-need, high-cost patients is complicated and requires practices to assess patient needs and available resources.  Careful planning is essential in the development of an effective care management strategy.  Successful programs meet both patient and practice needs in a sustainable and cost-beneficial manner.3  Practices seeking to adopt or expand care management programs should consider the level of staffing they will need to implement a team-based, patient-centered approach to care delivery."]
[null,"About the Assessment"]
[null,null,"This Care Management Capabilities and Readiness Assessment consists of four self-assessment sections that are intended to assist practices in determining:  (1) care management guiding principles, (2) care manager minimum qualifications, 3) care manager responsibilities, and (4) care management engagement readiness.  Educational references are included for each self-assessment statement.  Content for the assessment was developed by the Maryland Health Care Commission in collaboration with stakeholders. "]
[null,"Assessment Sections"]
[null,null,"Section 1:  Care Management Guiding Principles:  Presents topics related to implementing and maintaining a care management program that aligns with key care management guiding principles."]
[null,null,"Section 2:  Care Manager Minimum Qualifications:  Includes care manager competencies that meet the needs of a practice, support its patient population, and optimize the delivery of care management service."]
[null,null,"Section 3:  Care Manager Responsibilities:  Outlines a care manager’s role in facilitating preventive care, supporting the continuity and coordination of care, and aligning with the needs of the practice and the patient population it serves."]
[null,null,"Section 4:  Care Management Engagement Readiness:  Shows areas of considerations for implementing a care management program."]
[null,"Instructions"]
[null,null,"Please be sure that you clicked \"Enable Content\" when you opened the file to enable the automation of the scoring.  Each subsection contains supporting guidance and self-assessment questions.  The supporting guidance is intended to provide context and direction for the questions.  To complete the self-assessment, select the response option that most accurately reflects your practice’s services or activities.  Depending on your practice’s needs and goals, you can choose to complete the section(s) that are most applicable to you.  The combined self-assessment score for Sections 1, 2 and 3 indicates the stage of development for your practice’s care management program.  Section scores can be used to develop action plans for implementing systems to support key program requirements. "]
[null,"Understanding Your Results"]
[null,null,"Overall score ranges have the following meanings:\n< 50 – The practice would benefit from increased awareness about how care management will affect practice processes and patient care.  Explore the Supporting Guidance and resources for more information on topics not yet considered.\n60-80 – Many factors associated with care management have been considered; however, additional awareness building is recommended.  Supporting Guidance and resources identified in the document will help increase practice readiness to adopt care management.\n90-100 – The practice is well positioned to implement care management.  Supporting Guidance and resources available in the documment will strengthen practice awareness of care management considerations."]
[]
[null,"Section 1:   Care Management Guiding Principles"]
[null,"Patient and Caregiver Awareness of Evidence-Based Care Management"]
[null,null,"Supporting Guidance","Does Your Practice ...","Yes","No","N/A"]
[null,1,"A coordinated approach to delivering patient and caregiver education can help lay the groundwork for acceptance of care management services.4\n","Coordinate awareness of care management across members of the care team?",3,null,null,{"$f":"+E22","v":3},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2]
[null,2,"Education includes awareness building around patient rights to decline and reinstate care management services.5\n","Identify and communicate directly with candidates for care management?",3,null,null,3]
[null,3,null,"Identify and communicate directly with caregivers of candidates for care management?",3,null,null,3]
[null,4,null,"Provide materials to patients about their rights to participate in a care management program?",3,null,null,3]
[null,5,"Advertising care management services in a practice can help raise awareness among patients and caregivers.6","Promote care management services to patients?",3,null,null,3]
[6,6,null,"Promote care management services to caregivers?",3,null,null,3]
[null,7,"Care managers can support self-management by understanding patients’ readiness to change, using motivational interviewing to set goals, and tracking progress towards these goals.7","Promote self-management of patients through motivational interviewing and eliciting patient-specific goals and strategies?",3,null,null,3]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I29=J29*3,\"N/A\",(COUNTIF(H22:H28,1)/(J29-COUNTIF(H22:H28,3))*100))","v":"N/A"},null,null,null,{"$f":"SUM(H22:H28)","v":21},{"$f":"COUNTA(H22:H28)","v":7},{"$f":"4/11","v":0.36363636363636365}]
[null,"Care Delivery Via a Patient-Centered and Flexible Care Model"]
[null,null,"Supporting Guidance","Does Your Practice...","Yes","No","N/A"]
[null,8,"Personalized care management outreach and dialogue with patients and caregivers are helpful to identify and address unique patient needs.8","Develop a shared care plan with patients?",3,null,null,{"$f":"+E32","v":3}]
[null,9,null,"Develop a shared care plan with caregivers?",3,null,null,3]
[null,10,"Face-to-face interaction can be the most effective method to provide care management services.9","Provide in-person care management services?",3,null,null,3]
[null,11,"Use of virtual visits via phone or videoconference can address non-urgent care or routine management of medical or psychiatric conditions.10","Offer virtual visits using telehealth when opportunities for face-to-face visits are limited (such as during the COVID-19 public health emergency)?",3,null,null,3]
[null,12,"Telephonic care management can be effective when the relationship with the patient and/or caregiver is already established.11","Provide telephonic care management when clinically indicated?",3,null,null,3]
[null,13,"Field-based care managers, who provide services outside of the practice, help to decrease unnecessary utilization by identifying patient needs and making connections with community-based resources.12","Employ field-based care managers?",3,null,null,3]
[null,14,"Partially embedding care managers, who provide in-person services in the practice at least part time, is an option, supplemented by telephonic or field-based services to meet patient and provider needs.13","Provide options for telephonic services with a partially embedded care manager?",3,null,null,3]
[null,15,null,"Provide options for field-based services with a partially embedded care manager?",3,null,null,3]
[null,16,"Initial patient engagement within the practice improves acceptance of practice resources.14","Leverage positive patient relationship with care manager to enhance acceptance of resources?",3,null,null,3]
[null,17,null,"Leverage positive caregiver relationship with care manager to enhance acceptance of resources?",3,null,null,3]
[11,18,"Including a pharmacist on the care team allows for improved medication adherence and optimization for patients.15","Include a pharmacist on the care team?",3,null,null,3,{"$f":"SUM(H32:H42)","v":33}]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I42=A42*3,\"N/A\",(COUNTIF(H32:H42,1)/(A42-COUNTIF(H32:H42,3))*100))","v":"N/A"}]
[null,"A Framework That Fosters Coordination Between Providers and Care Team Members"]
[null,null,"Supporting Guidance","Does Your Practice...","Yes","No","N/A"]
[null,19,"Meetings and team huddles are a great way for the care team to consider process issues with care management.16","Include care managers in weekly or monthly meetings?",3,null,null,{"$f":"+E46","v":3}]
[null,20,null,"Involve the care manager, provider, and medical assistant in daily team huddles?",3,null,null,{"$f":"+E47","v":3}]
[null,21,"Develop referrals to consultants so that the specific question being asked is clear, and all needed information accompanies the referral so that services are not duplicated and the patient’s story is shared effectively.17","Use carefully crafted referrals for specialists?",3,null,null,{"$f":"+E48","v":3}]
[null,22,null,"Use templates/forms for consultation notes?",3,null,null,{"$f":"+E49","v":3}]
[5,23,"Standard care plan formats may include three components:  the medical plan created by the provider, the self-management action plan created by the patient, and the care management implementation plan.18","Include all three components in care plans:  1)  the medical plan created by the provider, 2) the self-management action plan created by the patient, and 3) the care management implementation plan?",3,null,null,{"$f":"+E50","v":3},{"$f":"SUM(H46:H50)","v":15}]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I50=A50*3,\"N/A\",(COUNTIF(H46:H50,1)/(A50-COUNTIF(H46:H50,3))*100))","v":"N/A"},"100% Possible"]
[null,"Accountability of Outcomes by the Care Team"]
[null,null,"Supporting Guidance","Does Your Practice...","Yes","No","N/A"]
[null,24,"Patients with complex needs often see multiple providers for different health conditions; coordinated care plans can help keep all providers informed about the patient’s needs and preferences.19","Share patient information, including the care plan, with the patient’s other providers as needed?",3,null,null,{"$f":"+E54","v":3}]
[null,25,"Regular meetings with the care team to discuss quality and utilization metrics and patient status enable level-setting between providers, care managers, and other team members.20","Hold regular meetings with the care team to discuss patient status, quality and utilization metrics, etc?",3,null,null,{"$f":"+E55","v":3}]
[null,26,"Quality improvement assessment processes should include feedback from patients and members of the care team on coordination issues, communication, workflow efficiencies, care delivery issues, and understanding of care management.21","Use quality improvement assessment processes?",3,null,null,{"$f":"+E56","v":3}]
[4,27,null,"Include patient feedback in assessment processes?",3,null,null,{"$f":"+E57","v":3},{"$f":"SUM(H54:H57)","v":12}]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I57=A57*3,\"N/A\",(COUNTIF(H54:H57,1)/(A57-COUNTIF(H54:H57,3))*100))","v":"N/A"}]
[null,"Care Teams Responsible for a Panel of Patients"]
[null,null,"Supporting Guidance","Does Your Practice...","Yes","No","N/A"]
[null,28,"Align care management with population needs to build relationships between the patient, provider, and care team.22","Assign care managers to teams based on patient needs?",3,null,null,{"$f":"+E61","v":3},null,null,null,{"$f":"97/2","v":48.5}]
[null,29,"Care teams can include different levels of care management based on patient risk stratification.23","Base the frequency of care management services on patient risk stratification?",3,null,null,{"$f":"+E62","v":3}]
[3,30,null,"Base the type of care management services on patient risk stratification?",3,null,null,{"$f":"+E63","v":3},{"$f":"SUM(H61:H63)","v":9}]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I63=A63*3,\"N/A\",(COUNTIF(E61:E63,1)/(A63-COUNTIF(H61:H63,3))*100))","v":"N/A"}]
[null,"Effective Linkages with Neighborhood/Community-Based Resources\t"]
[null,null,"Supporting Guidance","Does Your Practice...","Yes","No","N/A"]
[null,31,"Patients should be given the opportunity to define family (e.g., mother, child, friends, partners, paid caregivers, or other nontraditional relationships) and the extent to which these individuals are involved in their care.24","Engage patient supports such as families and caregivers?",3,null,null,{"$f":"+E67","v":3}]
[100,32,"Contacting community resources ensures that information provided to patients is accurate and up to date.25","Call community resources on patients’ behalf?",3,null,null,{"$f":"+E68","v":3}]
[null,33,"Developing knowledge about and relationships with resources available at the local, state, and national levels prior to meeting patients helps care managers make the most appropriate referral decisions.26","Maintain awareness of and relationships with resources that are available at the local level?",3,null,null,{"$f":"+E69","v":3}]
[null,34,null,"Maintain awareness of and relationships with resources that are available at the state level?",3,null,null,{"$f":"+E70","v":3}]
[5,35,null,"Maintain awareness of and relationships with resources that are available at the national level?",3,null,null,{"$f":"+E71","v":3}]
[5,null,"% Score (out of 100)",null,{"$f":"IF(I72=A72*3,\"N/A\",(COUNTIF(E67:E71,1)/(A72-COUNTIF(H67:H71,3))*100))","v":"N/A"},null,null,null,{"$f":"SUM(H67:H71)","v":15},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null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[]
[6,null,"Section 1 \n% Score (out of 100)",null,{"$f":"IF(I74=35*3,\"N/A\",(COUNTIF(H22:H72,1)/(J74-COUNTIF(H22:H72,3))*100))","v":"N/A"},{"$f":"IF(G74=I74*3,\"N/A\",(COUNTIF(G77:G96,1)/(I74-COUNTIF(G77:G96,3))*100))","v":0},{"$f":"IF(I74=J74*3,\"N/A\",(COUNTIF(H77:H96,1)/(J74-COUNTIF(H77:H96,3))*100))","v":"N/A"},null,{"$f":"+SUM(H22:H74)","v":105},35]
[]
[null,"Section 2:  Care Manager Minimum Qualifications"]
[null,"Customer Service Skills"]
[null,null,"Supporting Guidance","Do(es) Your Care Manager(s)...","Yes","No","N/A"]
[null,36,"Effective communication supports patient outcomes and safety.27","Have excellent written and verbal communication skills?",3,null,null,{"$f":"+E79","v":3}]
[null,37,"Community engagement and patient outreach are essential to delivering patient-centered and integrated health services.28","Establish effective working relationships with internal and external customers?",3,null,null,{"$f":"+E80","v":3}]
[null,38,null,"Prioritize customer service issues and promote positive interpersonal relationships among patients, providers, and the general public?",3,null,null,{"$f":"+E81","v":3}]
[null,39,"Patient and family advisors are valuable partners in improving the quality of health care.29","Work with patients/families in a variety of diverse physical conditions and social/cultural environments, including office, facility, and patients’ homes?",3,null,null,{"$f":"+E82","v":3}]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I83=J83*3,\"N/A\",(COUNTIF(E79:E82,1)/(J83-COUNTIF(H79:H82,3))*100))","v":"N/A"},null,null,null,{"$f":"SUM(H79:H82)","v":12},4]
[null,"Analytical/Problem Solving Skills"]
[null,null,"Supporting Guidance","Do(es) Your Care Manager(s)...","Yes","No","N/A"]
[null,40,"Patient data can be used to identify patients who may benefit from specific services, monitor patient progress, track health outcomes, and lower the cost of care.30","Understand how to analyze patient-specific quality and utilization reports in order to stratify the practice panel and develop a targeted care management strategy?",3,null,null,{"$f":"+E86","v":3}]
[null,41,"Care managers often need to make independent decisions and, at times, provide services typically provided by other practice staff.31","Make independent decisions in accordance with established policies and procedures?",3,null,null,{"$f":"+E87","v":3}]
[null,42,"Assessing patient health information helps care managers identify patient needs, goals, and target outcomes; key components of a patient’s care plan.32","Use critical thinking skills to perform analysis, evaluation, and interpretation of patient information?",3,null,null,{"$f":"+E88","v":3}]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I89=J89*3,\"N/A\",(COUNTIF(E86:E88,1)/(J89-COUNTIF(H86:H88,3))*100))","v":"N/A"},null,null,null,{"$f":"SUM(H86:H88)","v":9},3]
[null,"Management Skills"]
[null,null,"Supporting Guidance","Do(es) Your Care Manager(s)...","Yes","No","N/A"]
[null,43,"Managing workplace stress prevents burnout common among medical professionals.33","Manage conflict, stress, and multiple simultaneous work demands?",3,null,null,{"$f":"+E92","v":3}]
[null,44,"Each member of the care team should have a clearly defined role while contributing to a cohesive team approach to patient-centered care.34","Work independently while collaborating with other team members?",3,null,null,3]
[null,45,"Clinical knowledge is important for care managers, who often have to make decisions independent of provider input and may lead care teams.35 ","Serve as a clinical resource person to staff?",3,null,null,3]
[null,46,"Adapting care management to patient needs, organizational changes, and other factors is central to providing effective care management.36 ","Prioritize and change processes to improve effectiveness and efficiency?",3,null,null,3]
[null,47,null,"Adapt to changing patient or organizational priorities?",3,null,null,3]
[null,48,"Cultural competence can help ensure that care is patient-centered and attentive to individual patients' needs and values.37","Understand cultural diversity and low literacy issues in care provision?",3,null,null,3]
[null,49,"Health information technology supports care management by enabling record entry, patient tracking, reporting, program assessment, etc.38","Have computer literacy skills including, but not limited to, data entry, retrieval, and report generation?",3,null,null,3,{"$f":"SUM(H92:H98)","v":21},7,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,nu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[null,null,"% Score (out of 100)",null,{"$f":"IF(I98=J98*3,\"N/A\",(COUNTIF(E92:E98,1)/(J98-COUNTIF(H92:H98,3))*100))","v":"N/A"}]
[]
[null,null,"Section 2  \n% Score (out of 100)",null,{"$f":"IF(I101=J101*3,\"N/A\",(COUNTIF(H79:H98,1)/(J101-COUNTIF(H79:H98,3))*100))","v":"N/A"},null,null,null,{"$f":"SUM(H79:H98)","v":42},14,{"$f":"+J132*3","v":54}]
[]
[null,"Section 3:  Care Manager Responsibilities"]
[null,"Administrative Services"]
[null,null,"Supporting Guidance","Do(es) Your Care Manager(s)...","Yes","No","N/A"]
[null,50,"Risk stratification helps practices better focus on their sickest patients, reduce costs, and improve care.39","Prioritize patients according to intensity, need, and required follow up?",3,null,null,{"$f":"+E106","v":3}]
[null,51,"The effectiveness of care management can be measured by the degree to which patients achieve care plan goals.40","Evaluate effectiveness of the care plan in meeting established care goals?",3,null,null,3]
[null,52,"To achieve successful care planning, promote patient-centered care, and effective evaluation, the plan of care and the interventions should be continuously revised, updated, and individualized based on assessed patient needs and their response to the care provided.41","Regulary revisit and revise care plan as needed to reflect changing needs, issues, and goals?",3,null,null,3]
[null,53,"Engaging a wider range of resources to connect patients with organizations within their community can help transform health care and improve overall well-being.42","Identify and utilize community resources to meet patient/caregiver needs?",3,null,null,3]
[null,54,"Referral management helps ensure prompt completion of services and efficient sharing of information.43 ","Engage with clinicians to determine referral needs, generate referrals and accompanying clinical info, and ensure coordination of care?",3,null,null,3]
[null,55,"The risk for communication breakdowns, redundancies, and medical errors can increase when disparate providers are involved, making it important that health care be synchronized and coordinated to achieve the best clinical results.44","Serve as a liaison to providers, patients, and caregivers for coordination of services?",3,null,null,3]
[null,56,"Electronic Health Records (EHRs) help providers better manage care for patients by providing accurate, up-to-date, and complete information at the point of care.45","Maintain EHR documentation of care managed population?",3,null,null,3]
[null,57,"Care gaps can be both harmful and costly; data can be leveraged to identify patients at risk.46","Review utilization and quality reports to identify gaps in care and patients needing additional care management support?",3,null,null,3]
[null,58,"Documentation is critical; lack of data captured and appropriately recorded in patient records can undermine quality improvement efforts.47","Ensure documentation meets current standards and policies?",3,null,null,3,{"$f":"SUM(H106:H114)","v":27},9]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I114=J114*3,\"N/A\",(COUNTIF(E106:E114,1)/(J114-COUNTIF(H106:H114,3))*100))","v":"N/A"}]
[null,"Patient Care"]
[null,null,"Supporting Guidance","Do(es) Your Care Manager(s)...","Yes","No","N/A"]
[null,59,"A holistic approach to care management addresses patients’ multiple physical, mental, and social needs, including comorbidities.48","Conduct holistic assessments for care managed population?",3,null,null,{"$f":"+E118","v":3}]
[null,60,"The active role of community health workers in the clinical care team and the community may expand patient access to preventive health care, improve care quality, and minimize health inequities.49","Coordinate efforts with care support team members such as community health workers?",3,null,null,{"$f":"+E119","v":3}]
[null,61,"Measuring health outcomes also provides the data needed to improve care and efficiency and allows teams to know they are succeeding.50","Monitor and evaluate patient progress?",3,null,null,{"$f":"+E120","v":3}]
[null,62,"Patients who have post-hospital follow-up are less likely to be readmitted; prompt follow-up has the potential to substantially improve patient care and reduce health care expenditure.51","Perform telephonic patient outreach within two business days of discharge to ensure patient has needed resources in place? ",3,null,null,{"$f":"+E121","v":3}]
[null,63,"Efficiently utilizing health information exchange services, including notification systems, significantly reduces the rate of emergency department utilization and unplanned 30-day hospital readmissions among patients of medical practices.52","Gather needed data from CRISP, the State-Designated HIE, to support prompt and effective hospital discharge follow up appointment(s) with provider(s)?",3,null,null,{"$f":"+E122","v":3}]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I123=J123*3,\"N/A\",(COUNTIF(E118:E122,1)/(J123-COUNTIF(H118:H122,3))*100))","v":"N/A"},null,null,null,{"$f":"SUM(H118:H122)","v":15},5]
[null,"Professional Services"]
[null,null,"Supporting Guidance","Do(es) Your Care Manager(s)...","Yes","No","N/A"]
[null,64,"A key role of care managers is advocacy, which includes coordinating payments from payers.53","Advocate for the patient in ensuring benefits are accessible and delivered?",3,null,null,{"$f":"+E126","v":3}]
[null,65,"Providers and payers working collectively provides greater opportunity to deliver better care, while also creating value for patients in their health plan and increasing treatment adherence.54","Develop collaborative working relationships with insurance case managers?",3,null,null,{"$f":"+E127","v":3}]
[null,66,"Professional boundaries protect both patient and health care professionals.  Trust is enhanced when limits are set and followed.55","Maintain appropriate professional boundaries imposed by legal, ethical, and professional standards?",3,null,null,{"$f":"+E128","v":3},null,null,null,"77-99",14]
[null,67,"Ensuring the integrity of the health information protection process is a shared responsibility of all health care providers and is vital to the fiduciary relationship with patients.  Health care professionals should contribute to the development and implementation of legislation, policies, and standards that protect patient privacy and the confidentiality of patient information.56","Maintain a working knowledge of, and adhere to, applicable federal and State regulations including, and not limited to, laws related to patient confidentiality, release of information, and HIPAA?",3,null,null,{"$f":"+E129","v":3},null,null,null,"102-143",37]
[null,null,"% Score (out of 100)",null,{"$f":"IF(I130=J130*3,\"N/A\",(COUNTIF(E126:E129,1)/(J130-COUNTIF(H126:H129,3))*100))","v":"N/A"},null,null,null,{"$f":"SUM(H126:H129)","v":12},4,null,null,{"$f":"SUM(M128:M129)","v":51}]
[]
[null,null,"Section 3 \n% Score (out of 100)",null,{"$f":"IF(I132=J132*3,\"N/A\",(COUNTIF(H106:H129,1)/(J132-COUNTIF(H106:H129,3))*100))","v":"N/A"},null,null,null,{"$f":"SUM(H106:H129)","v":54},{"$f":"+J114+J123++J130","v":18},null,null,{"$f":"+J132*3","v":54}]
[]
[]
[null,"Total % Score for all 3 Sections  (out of 100)",null,null,{"$f":"IF(I135=67*3,\"N/A\",(COUNTIF(H22:H132,1)/(J135-COUNTIF(H22:H132,3))*100))","v":"N/A"},null,null,null,{"$f":"+I74+I101+I132","v":201},{"$f":"J74+J101+J132","v":67}]
[]
[]
[null,"Section 4: Care Management Engagement Readiness"]
[]
[null,null,"Supporting Guidance","Does Your Practice Have...","Yes","No","N/A"]
[null,68,"Close collaboration with payers and accountable care organizations is recommended to build sustainable payment models in complex care.57","An agreement with payer(s), or is your practice enrolled in a program that supports the cost of care management by your practice?",3,null,null,{"$f":"+E141","v":3}]
[null,69,"Engaged clinicians provide the fundamental insight and leadership necessary for health care transformation efforts to succeed.58","Clinicians on board and ready to embrace value-based care? ",3,null,null,{"$f":"+E142","v":3}]
[null,70,"Team-based care has the potential to improve care quality and efficiency.59","Clinicians on board and ready to embrace team-based care?",3,null,null,3]
[null,71,"Commitment from clinician leadership is paramount for the implementation and success of a care management structure.60","Practice leadership fully committed to investment in care management and transformation of care?",3,null,null,3]
[null,72,"It is important to define the roles and responsibilities of the care manager with a clear job description.61","Personnel to fulfill the role of care manager, or a strategy to recruit such personnel?",3,null,null,3]
[null,73,"Reorganizing care delivery without a reimbursement or cost sharing model to cover care coordination can be a significant expense.62","A sustainability plan based on a profit and loss estimate for your proposed care management program ?",3,null,null,3]
[null,74,"Effectively managing patients with complex clinical and social needs requires thoughtful integration of health care and social services.63","Partnerships with external resources to provide or supplement your care management resources?",3,null,null,3]
[null,75,"Successful care management programs require investments in personnel, IT support, and additional resources to support cross-continuum care coordination and ongoing quality improvement initiatives.  A thorough organizational readiness assessment of organizational culture, infrastructure needs, operational capability, and performance measurement capabilities should be conducted.64, 65","A logistical assessment of the impact a care management program will have on your practice in terms of hard ware, soft ware, space, desk, telephone, etc?",3,null,null,3]
[null,null,"% Score (out of 100)",null,{"$f":"IF(J149=K149*3,\"N/A\",(COUNTIF(E141:E148,1)/(K149-COUNTIF(H141:H148,3))*100))","v":"N/A"},null,null,null,null,{"$f":"SUM(H141:HI148)","v":24},8]

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[]
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[]
[null,1,"Patient Participation in Care Management:  Are They Aware?  The American Journal of Accountable Care"]
[null,null,"www.ajmc.com/journals/ajac/2017/2017-vol5-n3/patient-participation-in-care-management-are-they-aware "]
[null,2,"Principles for Patient and Family Partnership in Care:  An American College of Physicians Position Paper, Annals of Internal Medicine"]
[null,null,"www.acpjournals.org/doi/10.7326/M18-0018 "]
[null,3,"Better Care Playbook, Center for Health Care Strategies"]
[null,null,"www.bettercareplaybook.org/plays/play-develop-coordinated-care-plans "]
[null,4,"Patient Experiences with Chronic Care Management Services and Fees:  A Qualitative Study, Journal of General Internal Medicine"]
[null,null,"www.ncbi.nlm.nih.gov/pmc/articles/PMC6374248/ "]
[null,5," Care Coordination Toolkit, Centers for Medicare & Medicaid Services (CMS)"]
[null,null,"innovation.cms.gov/files/x/aco-carecoordination-toolkit.pdf  "]
[null,6,"Care Management - An Implementation Guide for Primary Care Practices, Agency for Healthcare Research and Quality (AHRQ)"]
[null,null,"www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/care-management-implementation-guide.pdf "]
[null,7,"Sample Patient Care and Office Form Templates, American College of Physicians"]
[null,null,"www.acponline.org/practice-resources/business-resources/office-management/patient-care-office-forms"]
[null,8,"Patient vs. Community Engagement:  Emerging Issues, Medical Care"]
[null,null,"www.ncbi.nlm.nih.gov/pmc/articles/PMC6136947/"]
[null,9,"Straight Talk About Case Manager Burnout, Professional Case Management"]
[null,null,"www.nursingcenter.com/journalarticle?Article_ID=3611776&Journal_ID=54025&Issue_ID=3611690   "]
[null,10,"Collect and Use Data for Quality Improvement, AHRQ"]
[null,null,"integrationacademy.ahrqstg.org/products/playbook/collect-and-use-data-quality-improvement "]
[null,11," Creating Patient-Centered Team-Based Primary Care, AHRQ"]
[null,null,"pcmh.ahrq.gov/page/creating-patient-centered-team-based-primary-care "]
[null,12," Introduction to the Case Management Body of Knowledge, Commission for Case Manager Certification"]
[null,null,"cmbodyofknowledge.com/content/introduction-case-management-body-knowledge "]
[null,13,"Patient- and Family-Centered Care, Institute for Patient- and Family-Centered Care (IPFCC)"]
[null,null,"www.ipfcc.org/about/pfcc.html"]
[null,14,"Patient-Centered Communication:  Basic Skills, American Family Physician"]
[null,null,"www.aafp.org/afp/2017/0101/p29.html "]
[null,15,"Care Management Plus:  Strengthening Primary Care for Patients with Multiple Chronic Conditions, The Commonwealth Fund"]
[null,null,"www.commonwealthfund.org/publications/case-study/2016/dec/care-management-plus-strengthening-primary-care-patients-multiple?redirect_source=/publications/case-studies/2016/dec/care-management-plus "]
[null,16," Helping Patients Help Themselves:  A Systematic Review of Self-Management Support Strategies in Primary Health Care Practice, PLoS ONE"]
[null,null,"www.ncbi.nlm.nih.gov/pmc/articles/PMC6675068/"]
[null,17,"Transforming Community Well-Being Through Patients' Lived Experiences, Journal of Business Research"]
[null,null,"www.sciencedirect.com/science/article/abs/pii/S0148296318306404?via%3Dihub "]
[null,18,"Involving the Family in Patient Care:  A Culturally Tailored Communication Model, Global Journal on Quality and Safety in Healthcare"]
[null,null,"meridian.allenpress.com/innovationsjournals-JQSH/article/1/2/33/434802/Involving-the-Family-in-Patient-Care-A-Culturally "]
[null,19,"Referral Management, Primary Care Team Guide, MacColl Center for Health Care Innovation at Kaiser Permanente Washington Health Research Institute"]
[null,null,"www.improvingprimarycare.org/work/referral-management# "]
[null,20,"Using Technology to Close Care Gaps, Improve Care Quality and Cost, Health Payer Intelligence"]
[null,null,"healthpayerintelligence.com/news/using-technology-to-close-care-gaps-improve-care-quality-and-cost "]
[null,21,"Optimize the Care Team, Institute for Healthcare Improvement"]
[null,null,"www.ihi.org/resources/Pages/Changes/OptimizetheCareTeam.aspx "]
[null,22,"STEPS to Care:  Care Team Coordination, Centers for Disease Control and Prevention (CDC)"]
[null,null,"www.cdc.gov/hiv/effective-interventions/treat/steps-to-care/dashboard/care-team-coordination.html "]
[null,23,"What Is Care Coordination?  New England Journal of Medicine Catalyst"]
[null,null,"catalyst.nejm.org/doi/full/10.1056/CAT.18.0291 "]
[]
[]
[null,1,"AHRQ, Care Management:  Implications for Medical Practice, Health Policy, and Health Services Research, August 2018.  Available at: "]
[null,null,"www.ahrq.gov/ncepcr/care/coordination/mgmt.html "]
[null,2,"National Association of Community Health Centers, Care Management Action Guide, July 2019.  Available at: "]
[null,null,"www.nachc.org/wp-content/uploads/2019/03/Care-Management-Action-Guide-Mar-2019.pdf "]
[null,3,"Health Care Transformation Task Force, Best Practices in Care Management Contracting for High-Need, High-Cost Population, July 2018.  Available at:  "]
[null,null,"hcttf.org/wp-content/uploads/2018/07/Care-Management-Contracting-Report_FINAL.pdf  "]
[null,4,"CMS, Care Coordination Toolkit, March 2019.  Available at:  "]
[null,null,"innovation.cms.gov/files/x/aco-carecoordination-toolkit.pdf "]
[null,5," Holtrop J.S., Chen Q., Piatt G., et al., Patient Participation in Care Management:  Are They Aware?  The American Journal of Accountable Care (2017).  Available at: "]
[null,null,"www.ajmc.com/view/patient-participation-in-care-management-are-they-aware"]
[null,6," Wilson C., O’Malley A., Bozzolo C., et al., Patient Experiences with Chronic Care Management Services and Fees:  A Qualitative Study, Journal of General Internal Medicine (2019).  Available at: "]
[null,null,"www.ncbi.nlm.nih.gov/pmc/articles/PMC6374248/"]
[null,7,"See n. 1, Supra."]
[null,8,"Health Affairs, To Identify Patients For Care Management Interventions, Look Beyond Big Data, April 2016.  Available at:  "]
[null,null,"www.healthaffairs.org/do/10.1377/hblog20160419.054528/full/"]
[null,9,"AHRQ, Designing and Implementing Medicaid Disease and Care Management Programs, October 2014.  Available at: "]
[null,null,"www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/index.html "]
[null,10,"Kaiser Family Foundation, Opportunities and Barriers for Telemedicine in the U.S. During the COVID-19 Emergency and Beyond, May 2020.  Available at:"]
[null,null,"www.kff.org/womens-health-policy/issue-brief/opportunities-and-barriers-for-telemedicine-in-the-u-s-during-the-covid-19-emergency-and-beyond/"]
[null,11,"See n. 8, Supra."]
[null,12," AHRQ, Care Management - An Implementation Guide for Primary Care Practices, November 2019.  Available at:  "]
[null,null,"www.ahrq.gov/evidencenow/tools/care-management.html "]
[null,13,"Ibid."]
[null,14,"See n. 6, Supra."]
[null,15," American Society of Health-System Pharmacists (ASHP), ASHP Statement on the Pharmacist’s Role in Primary Care.  Available at:  "]
[null,null,"pubmed.ncbi.nlm.nih.gov/10459388/"]
[null,16,"See n. 10, Supra."]
[null,17,"The American College of Physicians offers sample templates for patient care and office forms here:  "]
[null,null,"www.acponline.org/practice-resources/business-resources/office-management/patient-care-office-forms"]
[null,18,"New Jersey Department of Human Services, Division of Medical Assistance & Health Services, Care Management Workbook, November 2019.  Available at:  "]
[null,null,"www.state.nj.us/humanservices/dmahs/news/Care_Management_Workbook.pdf"]
[null,19,"Center for Health Care Strategies, Better Care Playbook.  Available at:"]
[null,null,"www.bettercareplaybook.org/plays/develop-coordinated-care-plans "]
[null,20,"American Medical Association, Team Meetings, Strengthen Relationships and Increase Productivity, May 2019.  Available at:  "]
[null,null,"edhub.ama-assn.org/steps-forward/module/2702508 "]
[null,21,"See n. 10, Supra."]
[null,22,"See n. 1, Supra. "]
[null,23," American Academy of Family Physicians, FPM, Risk Stratification:  A Two-Step Process for Identifying Your Sickest Patients, June 2019.  Available at:"]
[null,null,"https://www.aafp.org/fpm/2019/0500/p21.html"]
[null,24,"Nickel W.K., Weinberger S.E., Guze P.A., Principles for Patient and Family Partnership in Care:  An American College of Physicians Position Paper, Annals of Internal Medicine (2018).  Available at:  "]
[null,null,"www.acpjournals.org/doi/10.7326/M18-0018"]
[null,25,"Becker’s Hospital Review, 7 Steps to Establish a Solid Social Service Referral Process, April 2017.  Available at:  "]
[null,null,"www.beckershospitalreview.com/care-coordination/7-steps-to-establish-a-solid-social-service-referral-process.html"]
[null,26,"See n. 10, Supra. "]
[null,27,"Hashim, M.J, Patient-Centered Communication:  Basic Skills, American Family Physician (2017).  Available at: "]
[null,null,"www.aafp.org/afp/2017/0101/p29.html "]
[null,28,"Kimminau K.S., Jernigan, C., LeMaster J., et al., Patient vs. Community Engagement:  Emerging Issues, Medical Care (2018).  Available at:  "]
[null,null,"www.ncbi.nlm.nih.gov/pmc/articles/PMC6136947/ "]
[null,29,"IPFCC, Patient- and Family-Centered Care.  Available at:  "]
[null,null,"www.ipfcc.org/about/pfcc.html"]
[null,30,"AHRQ, Collect and Use Data for Quality Improvement.  Available at:  "]
[null,null,"integrationacademy.ahrqstg.org/products/playbook/collect-and-use-data-quality-improvement "]
[null,31,"See n. 10, Supra."]
[null,32,"Commission for Case Manager Certification, Introduction to the Case Management Body of Knowledge.  Available at:  "]
[null,null,"cmbodyofknowledge.com/content/introduction-case-management-body-knowledge "]
[null,33,"Zawalski S., Mann C., Straight Talk About Case Manager Burnout, Professional Case Management (2016).  Available at:  "]
[null,null,"www.nursingcenter.com/journalarticle?Article_ID=3611776&Journal_ID=54025&Issue_ID=3611690"]
[null,34,"AHRQ, Creating Patient-Centered Team-Based Primary Care, March 2016.  Available at: "]
[null,null,"pcmh.ahrq.gov/page/creating-patient-centered-team-based-primary-care "]
[null,35,"See n. 10, Supra."]
[null,36,"See n. 1, Supra."]
[null,37,"See n. 33, Supra."]
[null,38,"The Commonwealth Fund, Care Management Plus:  Strengthening Primary Care for Patients with Multiple Chronic Conditions, December 2016.  Available at:  "]
[null,null,"www.commonwealthfund.org/publications/case-study/2016/dec/care-management-plus-strengthening-primary-care-patients-multiple?redirect_source=/publications/case-studies/2016/dec/care-management-plus"]
[null,39,"Dera J.D.,  Risk Stratification:  A Two-Step Process for Identifying Your Sickest Patients, Family Practice Management (2019).  Available at:"]
[null,null,"www.aafp.org/fpm/2019/0500/p21.html "]
[null,40,"See n. 2, Supra."]
[null,41,"Nieves R., 3 Ways to Achieve Patient-Centered Care with Interdisciplinary Collaboration, Elsevier Connect (2018).  Available at: "]
[null,null,"www.elsevier.com/connect/3-ways-to-achieve-patient-centered-care-with-interdisciplinary-collaboration "]
[null,42,"Gallan A.S., McColl-Kennedy J.R., Barakshina T., et al., Transforming Community Well-Being Through Patients' Lived Experiences, Journal of Business Research (2019).  Available at: "]
[null,null,"www.sciencedirect.com/science/article/abs/pii/S0148296318306404?via%3Dihub"]
[null,43,"Primary Care Team Guide, Referral Management.  Available at: "]
[null,null,"www.improvingprimarycare.org/work/referral-management# "]
[null,44," New England Journal of Medicine Catalyst, What Is Care Coordination?  January 2018.  Available at:  "]
[null,null,"catalyst.nejm.org/doi/full/10.1056/CAT.18.0291 "]
[null,45,"HealthIT, What are the Advantages of Electronic Health Records?  May 2019.  Available at:  "]
[null,null,"www.healthit.gov/faq/what-are-advantages-electronic-health-records "]
[null,46,"Health Payer Intelligence, Using Technology to Close Care Gaps, Improve Care Quality and Cost, May 2019.  Available at: "]
[null,null,"healthpayerintelligence.com/news/using-technology-to-close-care-gaps-improve-care-quality-and-cost "]
[null,47,"Ibid."]
[null,48,"AHRQ, Designing and Implementing Medicaid Disease and Care Management Programs, October 2014.  Available at:  "]
[null,null,"www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm3.html"]
[null,49,"Lewis C.M., Gamboa-Maldonado T., Carlos Belliard J. et al., Patient and Community Health Worker Perceptions of Community Health Worker Clinical Integration, Journal of Community Health (2019).  Available at: "]
[null,null,"doi.org/10.1007/s10900-018-0566-1"]
[null,50,"Teisberg E., Wallace S., O'Hara S., Defining and Implementing Value-Based Health Care: A Strategic Framework. Academic Medicine. (2020).  Available at:"]
[null,null,"https://pubmed.ncbi.nlm.nih.gov/31833857/"]
[null,51," Alper E., O'Malley T.A., Greenwald J., Hospital Discharge and Readmission, UpToDate (2021).  Available at:  "]
[null,null,"www.uptodate.com/contents/hospital-discharge-and-readmission#H17 "]
[null,52,"Fecher K., McCarthy L., Porreca D.E. et al., Assessing the Benefits of Integrating Health Information Exchange Services into the Medical Practices’ Workflow, Information Systems Frontiers (2020).  Available at: "]
[null,null,"doi.org/10.1007/s10796-019-09979-x"]
[null,53,"Health Catalyst, Six Need-to-Know Guidelines for Successful Care Management, January 2019.  Available at: "]
[null,null,"www.healthcatalyst.com/insights/care-management-success-6-key-elements "]
[null,54,"The Doctor Weighs In, The Value of Transparency in Payer-Provider Relationships, September 2019.  Available at: "]
[null,null,"thedoctorweighsin.com/transparency-payer-provider-relationships/ "]
[null,55,"Witwer S.G., Maintaining Healthy Relationships with Patients and Families, American Academy of Ambulatory Care Nursing Viewpoint (2019).  Available at:  "]
[null,null,"search.proquest.com/openview/1799460bc1137474644ee4db0051470f/1?pq-origsite=gscholar&cbl=46506 "]
[null,56,"American Nurses Association, American Nurses Association Position Statement on Privacy and Confidentiality, June 2015.  Available at:"]
[null,null,"www.nursingworld.org/~4ad4a8/globalassets/docs/ana/position-statement-privacy-and-confidentiality.pdf "]
[null,57,"Humowiecki M., Kuruna T., Sax R., et al., Blueprint for Complex Care:  Advancing the Field of Care for Individuals with Complex Health and Social Needs, National Center for Complex Health and Social Needs (2018).  Available at:"]
[null,null,"www.nationalcomplex.care/wp-content/uploads/2019/03/Blueprint-for-Complex-Care_UPDATED_030119.pdf "]
[null,58,"Harvard Medical School, Engaging Physicians to Lead Change in Health Care, January 2020.  Available at:"]
[null,null," postgraduateeducation.hms.harvard.edu/trends-medicine/engaging-physicians-lead-change-health-care"]
[null,59,"Sheridan B., Chien A.T., Peters A.S., et al., Team-Based Primary Care:  The Medical Assistant Perspective, Health Care Management Review (2018).  Available at:"]
[null,null,"pubmed.ncbi.nlm.nih.gov/27849646/"]
[null,60,"Tomoaia-Cotisel A., Farrell, T.W., Solberg L.I., et al., Implementation of Care Management:  An Analysis of Recent AHRQ Research, Medical Care Research and Review (2018).  Available at: "]
[null,null,"pubmed.ncbi.nlm.nih.gov/27789628/"]
[null,61,"See n. 39, Supra."]
[null,62,"Williams M.D., Asiedu G.B., Finnie D., et al., Sustainable Care Coordination:  A Qualitative Study of Primary Care Provider, Administrator, and Insurer Perspectives, BMC Health Services (2019).  Available at: "]
[null,null,"www.ncbi.nlm.nih.gov/pmc/articles/PMC6359857/"]
[null,63,"Amarasingham R., Xie B., Karam A., et al., Using Community Partnerships to Integrate Health and Social Services for High-Need, High-Cost Patients, Commonwealth Fund (2018).  Available at: "]
[null,null,"www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2018_jan_amarasingham_integrating_health_social_services_high_need_high_cost_ib.pdf."]
[null,64," Healthcare Innovation, How to Calculate the Elusive ROI for Care Management, February 2021.  Available at:"]
[null,null,"www.hcinnovationgroup.com/population-health-management/care-management/article/21208749/how-to-calculate-the-elusive-roi-for-care-management"]
[null,65,"Health Care Transformation Task Force, Best practices in Care Management Contracting for the High-Need, High-Cost Population, July 2018.  Available at: "]
[null,null,"hcttf.org/wp-content/uploads/2018/07/Care-Management-Contracting-Report_FINAL.pdf"]