• 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)(3 page PDF) and the five key functions of the Comprehensive Primary Care Plus (CPC+) initiative.

    Learn more about access and continuity, one of the five key functions of medical homes.

    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 programs increase patient satisfaction and improve outcomes, while reducing costs to the health care system through avoidance of unnecessary hospital and emergency department utilization. Examples of care management activities and services include:  

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

    For examples of care management implementation in practice, see the Robert Graham Center's Bright Spots in Care Management report (www.graham-center.org).

    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.

    Identifying a patient's health risk category is the first step toward planning, developing, and implementing a personalized care plan by the care team, in collaboration with the patient. For some, the plan may address a need for more robust care coordination with other providers, intensive care management, or collaboration with community resources.

    Implement Risk-Stratified Care Management

    The AAFP has created a comprehensive rubric to help you identify your patients' risk category. This full-color PDF can be printed legal- or poster-size for guidance through the RCSM process.

    Free for Members

    Log in to your AAFP member account and download the PDF for free (a $50.00 value)!

    Download Free

    Non-members: Purchase the downloadable, full-color PDF.
    Non-member price: $50.00

    Learn More

    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. 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% (via the Commonwealth Fund Issue Brief, May 2011(www.commonwealthfund.org).)

    Efforts to implement RSCM have the added benefit of preparing a practice to respond to payment reform. Value-based care models require practices to have a method for systematically categorizing and monitoring their patient populations, so that risk-adjusted payments can be made for the additional care and resources the health care team provides to high-risk patients.

    The Cost of Care Management

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

    This activity includes (but is not limited to):

    The resources necessary to deliver care management vary widely depending upon the program and characteristics of the primary care practice implementing the program. A Robert Graham Center presentation (www.graham-center.org) found services covered under public and private care management programs ranged from simple teaching plans with educational modules to using registered nurses and social workers as care managers.

    The AAFP has tools and resources to help you implement care management services in your practice. Learn more about Medicare's CCM services and access the AAFP's CCM Toolkit for step-by-step instructions on implementing these activities in your practice to increase revenue and improve patient care.