• Key Functions of a Medical Home

    Care Management

    The American Academy of Family Physicians defines a medical home as one that is based on the Joint Principles of the Patient-Centered Medical Home (PCMH).

    Learn more about care management, one of the five key functions of medical homes, and check out new resources and tools.

    What Is Care Management?

    Care management refers to activities performed by health care professionals with a goal of facilitating coordinated patient care across the health care system.

    Care management increases patient satisfaction and improves outcomes while reducing costs to the health care system by avoiding unnecessary hospital and emergency department utilization. Components of care management include:  

    • Patient education
    • Medication management and adherence support
    • Risk stratification
    • Population management
    • Coordination of care transitions
    • Care planning

    The goal of care management and coordination is to individualize health care to meet each patient’s specific needs. Health care systems that are patient-centric and outcome-driven and include payment structures that support services patients need will be better aligned to meet this goal. In the current fee-for-service (FFS) health landscape, this alignment is often difficult to accomplish. But the landscape is changing.

    With the shift away from FFS, primary care serves as the foundation of value-based payment (VBP). Similarly, care management and coordination are integral to aligning and meeting the goals of VBP. Practices that utilize the flexibility VBP provides, along with innovative care delivery, will thrive in meeting the quadruple aim of health care—better patient outcomes, lower costs, improved patient experience, and improved clinician experience.

    To learn more about how care management and coordination function in the VBP landscape, see the FPM Supplement “Paving the Path to Value: Care Management and Coordination.” For examples of care management implementation in practice, see the report “Bright Spots in Care Management in Medicare Advantage” from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

    Risk-stratified Care Management

    Risk-stratified care management (RSCM) is the process of assigning a health risk status to a patient and using the patient’s risk status to direct and improve care. The goal of RSCM is to help patients achieve the best health and quality of life possible by preventing chronic disease, stabilizing current chronic conditions, and preventing acceleration to higher-risk categories and higher associated costs.

    The practice first assigns a health risk status to a patient, and then care team members collaborate with the patient to plan, develop, and implement an individualized care plan. For some, the plan may address a need for more robust care coordination with other health care professionals, intensive care management, or collaboration with community resources.

    In a practice panel of 1,000 patients, there will likely be close to 200 patients (20%) who could benefit from an increased level of support. According to The Commonwealth Fund, this 20% of the population accounts for 80% of the total health care spending in the United States, with the very highest medical costs concentrated in the top 1%.

    Efforts to implement RSCM have the added benefit of preparing a practice to respond to payment reform. With VBP tied to performance on quality, cost, and utilization, practices must understand which patients they are responsible for managing. RSCM allows the practice to focus valuable time, resources, and effort on patients most likely to benefit from increased support and care management.

    Learn more about how risk stratification ties to VBP in the FPM supplement “Keys to High-quality, Low-cost Care: Empanelment, Attribution, and Risk Stratification.”

    Watch risk-stratified care management in action in the Family Medicine Practice Hack: Behavioral Health Integration.

    Implement Risk-stratified Care Management


    The RSCM rubric provides a conceptual framework to aid your practice in identifying your patients’ health risk category.

    Members: Free ($50 value)
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    Nonmembers: $50
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    Scoring Algorithm

    This tool enables practices to generate a score and associated risk level to identify patients who may benefit from longitudinal care management services.   

    Members: Free ($50 value)
    Nonmembers: $50
    Learn more.  


    The Cost of Care Management

    Significant activity across the country is currently focused on optimizing care management in primary care practices and working to deliver high-quality care at lower costs, especially related to the adoption of the five functions of the medical home.

    The resources needed to deliver care management vary widely depending on practice characteristics, patient populations, payer mix, and the types of payment models in which the practice participates. the program and characteristics of the primary care practice implementing the program. Startup costs for care management can be daunting, especially for practices with limited personnel and resources.

    The AAFP has tools and resources to help you implement care management in your practice and understand what payment can look like in varying payment arrangements, from FFS to VBP. Whether you are just starting to integrate components of care management into your practice or are looking to expand your existing efforts, explore the following resources designed to increase revenue and improve patient care.

    Care Management Tools and Resources: