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‘Care Management Plus’ for people with chronic conditions

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Healthy-looking Salt Lake City, Intermountain Healthcare’s headquarters.

Care Management Plus is a health-care delivery model designed for older adults with multiple chronic conditions used at Intermountain Healthcare, an integrated care-delivery system serving patients in Utah and Idaho.

A Commonwealth Fund report on the program says  that the idea is not only to improve quality, including coordination, of care but also to cut costs and support primary-care providers who treat these high-cost patients.

It is based on the Chronic Care Model, which list six essential elements for high-quality chronic-disease care: the community, the health system, self-management support, delivery-system design, decision support, and clinical information systems.

“Care Management Plus embeds care managers in clinics to help high-risk patients with multiple needs, ‘’ reports the Commonwealth Fund, and it uses specialized Web applications to provide clinical teams with care-management tools.

The program’s Integrated Care Coordination Information System (ICCIS)  application “sits on top of” a patient’s electronic health record and is adaptable for use with several EHR systems.

The Commonwealth Fund article says that ICCIS lets practices:

  • “Track patient encounters and record activities
  • “Create “tickler,” or reminder, lists
  • “Perform assessments for depression and functional status .
  • “See, at a glance, in a ‘Patient Worksheet,’ a patient’s chronic conditions, medications, pertinent lab results, and receipt of preventive care, as well as their goals and the results of assessments of depression and functional status, and
  • “Generate clinic summary and quality performance reports.’’

To read the whole report, please hit this link.



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