Care Management Blog

Healthcare’s goal is to cure. However, Advance Care Planning (ACP), or end-of-life planning, can address the tension between care at all costs and ensuring an individual’s wishes are met when they can’t speak for themselves.

Medicare’s Annual Wellness Visit (AWV) can be instrumental in improving care quality for older adults. This yearly assessment captures information about a patient’s health and functioning to document disease and identify new or worsening risk factors.

Several factors are driving the adoption of team-based care coordination. Workforce shortages exacerbated by the pandemic, a growing population of adults living longer with chronic disease, and the shift toward value-based care models top the list.

Unaddressed health-related social needs (HRSN) can make achieving care plan goals difficult.

Policy and value-based payment models promote the importance of managing transitions of care.

Patient assessments are used in various settings by different medical professionals. They can be part of a proactive process (e.g., during an Annual Wellness Visit) or when some symptoms or signals indicate further assessment is necessary.

Three approaches have converged to improve clinical outcomes, elevate the quality of care, and decrease barriers that stand in the way of patient-centered healthcare. They are:

An aging, chronically ill population has put pressure on healthcare to lower costs and deliver proactive primary medicine. For this reason, healthcare payment models are moving towards value-based contracts, where the provider’s compensation is tied to care quality and patient outcomes.