Embedding care management in the medical home: a case study

J Prim Care Community Health. 2014 Apr 1;5(2):97-100. doi: 10.1177/2150131913519128. Epub 2014 Jan 10.


Introduction: Care managers are playing increasingly significant roles in the redesign of primary care and in the evolution of patient-centered medical homes (PCMHs), yet their adoption within day-to-day practice remains uneven and approaches for implementation have been minimally reported. We introduce a strategy for incorporating care management into the operations of a PCMH and assess the preliminary effectiveness of this approach.

Methods: A case study of the University of North Carolina at Chapel Hill Family Medicine Center used an organizational model of innovation implementation to guide the parameters of implementation and evaluation. Two sources were used to determine the effectiveness of the implementation strategy: data elements from the care management informatics system in the health record and electronic survey data from the Family Medicine Center providers and care staff.

Results: A majority of physicians (75%) and support staff (82%) reported interactions with the care manager, primarily via face-to-face, telephone, or electronic means, primarily for facilitating referrals for behavioral health services and assistance with financial and social and community-based resources. Trend line suggests an absolute decrease of 8 emergency department visits per month for recipients of care management services and an absolute decrease of 7.5 inpatient admissions per month during the initial 2-year implementation period.

Discussion: An organizational model of innovation implementation is a potentially effective approach to guide the process of incorporating care management services into the structure and workflows of PCMHs.

Keywords: care management; implementation; medical home; primary care; quality improvement.

MeSH terms

  • Adult
  • Delivery of Health Care, Integrated / organization & administration*
  • Emergency Service, Hospital / statistics & numerical data
  • Female
  • Humans
  • Interprofessional Relations
  • Male
  • North Carolina
  • Nursing Homes / organization & administration*
  • Organizational Case Studies
  • Patient Care Management / organization & administration*
  • Patient-Centered Care / organization & administration
  • Quality Improvement / organization & administration*