Case Management Information System

jessievenegas Jessie Venegas — 11/01/2009

Community Care of North Carolina (CCNC) is an EPCCM program built on the tenets of the medical home model. It includes core care management elements such as risk assessment, emergency room utilization review, disease specific case management, and pharmaceutical management. These care management strategies are delivered through 14 participating Community Care Networks, which consist of more than 3,000 physicians and numerous community support services. North Carolina is also piloting a Chronic Care Project for its highest-risk, highest-cost ABD/SSI beneficiaries with complex needs. The pilot program uses nine of the 14 Community Care Networks to provide enhanced medical home services (e.g., intense case management and interdisciplinary care plans) through the use of care coordinators. This program uses software that providers use to access diagnosis and utilization data. Stakeholders including case managers, Community Care Networks, and providers can use the data to identify enrollees for targeted care management, track interventions, assess adherence to evidence-based guidelines, and review clinical outcomes and changes in utilization patterns.

Fragility, pluripathology/polipathology and/or complex chronic diseases

Goals Prevention:
Funding for detection programs
Goals Detection:
Advances public education on the importance of early detection , Shows new evidence on the importance of early detection, including guidelines of effective practices , Provides registries and patients contact systems , Promotes early intervention through primary health care measures
Goals Treatment:
Develop basic elements for an integrated health system , Provides support health policies to facilitate the planning and integration at locally and regionally , Strengthens cooperative local groups to provide integral services , Improving access to health services across the entire spectrum, from prevention to treatment , Ensures the best quality of health services , Promotes the training of health professionals , It facilitates the management by processes , Emphasizes the care of pluri-pathological and fragile patients , Promotes electronic health information systems to improve the quality of care
Goals self-management:
Refocuses the health system to support self-management , Promotes patient involvement in planning services , Improving support services with an emphasis on peer support, the disabled and carers

Progress

UNITED STATES OF AMERICA

North Carolina

North Carolina

Raleigh

Raleigh
Practices Map

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