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: 11/09/2021

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 Tool

Chronic Care Management

02/01/2015 Chronic Care Management and Other New CPT Codes Point of Care Tool
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 Tool
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? Tool
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 Tool

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
12/01/2021 Put Your Clinical Data to Work With a Registry new

Risk-Stratified Care Management

06/01/2019 Risk Stratification: A Two-Step Process for Identifying Your Sickest Patients Tool
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 Point of Care
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

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