Topic Collection

Care Management

Editors' Choice of Best Available Content

Care management activities facilitate coordinated patient care across the health care system, leading to increased patient satisfaction, improved outcomes, and reduced costs through avoidance of unnecessary hospital and emergency department utilization.

Last Update: 03/15/2021

Care Planning
12/01/2019	Advance Care Planning: How to Have the Conversation You Want With Your Patients
04/01/2021	Care Management and the Quadruple Aim
04/01/2021	Care Management in the Real World: A Small, Private Practice's Journey
06/01/2013	Engaging Patients in Collaborative Care Plans
10/01/2012	Making Medicare Wellness Visits Work in Practice
Chronic Care Management
02/01/2015	Chronic Care Management and Other New CPT Codes
06/01/2015	Answers to Your Questions About Chronic Care Management
10/01/2010	Health Coaching for Patients With Chronic Illness
	Chronic care management coding updates for 2020 [Getting Paid]
Community Resources
10/01/2014	Caring for Seniors: How Community-Based Organizations Can Help
06/01/2018	A Practical Approach to Screening for Social Determinants of Health
Medication Management and Adherence
10/01/2016	Practical Ways to Improve Medication Adherence
04/01/2013	Medication Adherence: We Didn't Ask and They Didn't Tell
06/01/2018	Deprescribing Unnecessary Medications: A Four-Part Process
04/01/2006	Can Your Patients Afford the Medications You Prescribe?
Panel Management
04/01/2007	Panel Size: How Many Patients Can One Doctor Manage?
04/01/2020	Panel Size Is Just a Number: A Rubric for Opening and Closing Panels
12/01/2019	The Right-Sized Patient Panel: A Practical Way to Make Adjustments for Acuity and Complexity
Population Management
12/01/2013	The Benefits of Using Care Coordinators in Primary Care: A Case Study
10/01/2017	Finding the Bright Spots in Value-Based Care
08/01/2016	Home Care Gets a New Place in the Medical Neighborhood
06/01/1998	It's Time to Start Practicing Population-Based Health Care
Risk Stratification
06/01/2019	Risk Stratification: A Two-Step Process for Identifying Your Sickest Patients
12/01/2016	Patient Attribution: Why It Matters More Than Ever
10/01/2016	HCC Coding, Risk Adjustment, and Physician Income: What You Need to Know
Transitional Care Management
06/01/2019	Transitional Care Management: Practical Processes for Your Practice
06/01/2013	Transitional Care Management Services: New Codes, New Requirements
12/01/2017	Making Sense of MACRA: Aligning Transitional Care Management With the Quality Payment Program
AAFP Resources
	Building the Business Case Slide Deck
	Care Management ROI Calculator
	Chronic Care Management Toolkit
	Medicare’s Chronic Care Management (CCM) services
	Medicare’s Transitional Care Management (TCM) services
	Paving the Path to Value: Care Management and Coordination [Supplement]
	Transitional Care Management Toolkit