Care Management Plus

This program is a cooperative project between the Oregon Health & Science University and The John A. Hartford Foundation. Our mission is to improve the quality of care for seniors and patients with chronic illnesses using care managers and information systems.

Care managers within primary care clinics can work with patients who have long-term chronic diseases, patients who need more education, patients who require more time to understand medications or any other aspect of their care. They focus on the needs and preferences of older adults and those with complex medical conditions.

As part of a five-year project supported through a grant from the John A. Hartford Foundation, Intermountain Healthcare developed a set of databases that care managers can use at the point of care to access disease-specific recommendations and reminders.

The system starts when a patient is referred into the care management program. About 3-5% of patients at an all ages primary care practice or 10% (or more) of a practice geared towards older adults might be referred. Once referred, the team - with the patient and the care manager at the center - assesses the needs of the patient and their family, co-creates a care plan, and acts as a catalyst to ensure the care plan occurs. Information technology helps assure everyone can Access and Add to the care plan, follow Best Practices, and Communicate.