Key Elements of Multicondition Collaborative Care Management
| Tasks and Objectives | Process | Participants |
|---|---|---|
| Identify goals or target | Collaborate to formulate specific and measurable targets (eg, BP, PHQ-9 [depression], HbA1c or BG, walk number of steps) | Patient, primary care physicians, care managers |
| Support self-care | Motivate, problem-solve to promote self-monitoring, adherence to medications, lifestyle change | Patient; care managers |
| Monitor progress | Systematic, proactive tracking, population-based | Patient, care manager, multi-disciplinary consultant |
| Treat-to-target case reviews | Weekly multidisciplinary caseload review, formulate treatment adjustment recommendations to primary care physician Case-by-case training Accountability for improving outcomes | Treat-to-target physician consultants, care manager |
| Care coordination | Communicate and coordinate (eg, EHR, telephone, fax, or in person) | Care manager |
BG = blood glucose; BP = blood pressure; EHR = electronic health record; HbA1c = glycated hemoglobin.