Implementing Integrated, Interdisciplinary Clinical Care Management in the Patient-Centered Medical Home

PDF icon Implementing Integrated, Interdisciplinary Clinical Care Management in the Patient-Centered Medical Home
July 08, 2014

Jeanne Cohen, M.S., R.N., PCMH CCE

Director of Clinical Care Management
Southcoast Accountable Care Organization

Christine Johnson, Ph.D.

Center for Health Policy and Research
University of Massachusetts Medical School

Judith L. Steinberg, M.D., M.P.H.

Deputy Chief Medical Officer, Commonwealth Medicine
Senior Director, Clinical Affairs
Clinical Associate Professor, Department of Medicine and Department of Family Medicine & Community Health
University of Massachusetts Medical School

Sai Sirisha Cherala M.D., M.P.H.

Assistant Professor
Family Medicine and Community Health
University of Massachusetts Medical School
  • MA Patient-Centered Medical Home Initiative 
  • Overview of Clinical Care Management
  • The CCM Continuum of Care: A Patient Case Study
    • Activity #1: Identifying the highest risk patient
    • Activity #2: Intake Assessment and developing an integrated care plan
  • Discussion: Evaluating care plan effectiveness/discharging patients from clinical care management 
  • Wrap-up
Topics: 
Patient-Centered Medical Home, Practice Improvement, Care Management