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Description
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Proactively manage chronic and preventive care for empaneled patients that could include one or more of the following:
Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; plan of care for chronic conditions; and advance care planning;
Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target;
Use pre-visit planning to optimize preventive care and team management of patients with chronic conditions;
Use panel support tools (registry functionality) to identify services due;
Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or
Routine medication reconciliation.
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