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Improving PCP Referrals to Care Management Toolkit

Integrating care management into the primary care work flow starts with strong relationships between primary care providers (PCPs) and care managers (CMs).

For many providers, the care management integration process proves challenging. Not all primary care physicians know about the benefits care management brings, and not every primary care practice has the technological infrastructure in place to make referring patients to care management easy.

Below, you'll find a toolkit to help facilitate collaboration between PCPs and CMs with four steps:

1. Structure a comprehensive onboarding process

2. Demonstrate and communicate the value of care management

3. Streamline PCP referral processes

4. Establish two-way feedback with PCPs

Step 1: Structure a comprehensive onboarding process

Not all primary care physicians understand the responsibilities of care managers, the services they provide patients, or the benefits they bring to a primary care office. Implementing a standardized, system-wide education program is an important first step toward maximizing the value of care management in your primary care practice and achieving system-wide quality standards.

In this section, you'll find tools to help care management leadership design and implement an education program that aims to familiarize primary care physicians and staff with care management services and establish care managers as key members of the practice’s team.

Start by designing a curriculum that addresses key topics and lessons, then designate responsibilities for each member of the care team, and outline referral pathways for each staff member.

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Download the templates:

 Blank Onboarding Plan Template
Care management leaders can use this sample strategic plan to design their own strategy for onboarding primary care physicians and staff to their care management program.

 Sample Lehigh Valley Health Network Care Team Compact
Our sample agreement delineates job responsibilities of different primary care staff members to reduce redundancies in patient care and help all members of the care team hold each other accountable.

 Blank Referral Pathway Template
Our template provides a guide to outlining appropriate care management referral pathways for different members of your primary care practice staff.

Step 2: Demonstrate and communicate the value of care management

Engaging systemwide stakeholders in care management requires generating and delivering a strong value proposition for the program. Although some stakeholders may intuitively understand the benefits of care management services, clearly defining the impact that care management has on both patients and providers can serve as a powerful method to boost engagement and improve referrals to the program.

The tools in this section help population health leaders demonstrate and communicate the value of care management to stakeholders across their organizations. They help quantify care management’s impact on the efficiency and efficacy of providers and cost savings to the health system and offer suggestions on how to share care management success stories in a persuasive format.

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 Care Management Value Calculator
This Excel tool quantifies the direct and indirect benefits of care management in terms of increased staff productivity and avoided costs to the health system.

 Care Management Newsletter Except
Use this sample newsletter from the Cedars-Sinai Medical Group to communicate the impact of care management on patients’ lives.

Step 3: Streamline PCP referral processes

Given PCPs' limited time and resources, care management leaders can use common sense principles to simplify the process by which providers submit referrals.

By creating a straightforward referral form, incorporating referrals into PCP workflows, and allowing PCPs to use an "opt out" methodology to determine which high risk patients would not benefit from care management, care management leaders not only make it easier for PCPs to submit referrals, but also ensure that the appropriate patients are being referred.

The tools in this section can help you redesign your care management referral form, identify points in the PCP workflow where referrals can easily occur, and determine if your organization is ready to use the opt-out review process.

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 Care Management Routing Slip
This tool provides an example of usable, streamlined care management referral form from Vanguard Medical Group.

Step 4: Establish two-way feedback with PCPs

Building support for care management among physicians is an important part of successfully integrating care management into primary care practices. However, strong initial support does not guarantee that primary care physicians and their staff will be continually satisfied with the assistance care management provides them and their patients. It is important that care management leadership continue to keep the lines of communication open between their team and PCPs.

To help care management leadership understand physicians' and staff's assessment of the efficacy of care management services, this section provides you with the Care Management Provider Satisfaction Survey template. The survey poses questions that highlight how physicians and staff perceive care management services and leadership. Survey results can help improve both relationships between care management and primary care office staff and your patients' experience with care management.

Start by designing your survey, and follow our engagement and communication plans to ensure maximum survey participation. We've provided you with sample email scripting to send to the recipients of your survey. And beyond the survey resources, we've offered a guide to ensure your team huddles are as efficient and effective as possible.

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 Care Management Provider Survey
Use this sample survey from Triad Healthcare Network as a guide when developing your own care management feedback survey.

 Team Huddles Daily Game Plan Sample
See a sample worksheet that Cambridge Health Alliance uses to provide structure for productive care team huddles.

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