Standards of care every patient should receive

Resource Allocation	~10 hrs/wk
Area of Focus	Ongoing engagement All patients enrolled & consented All/underlying patient needs
Activity Breakdown	All “Good Care Mgmt.” Respond to all messages Engage pts Behind/Off Track Obtaining consent for all patients “Coach” patients to goals
Expected Result	80% - 100% Qualification* rate

*Note: For 500 patients, we recommend a dedicated full-time Care Manager (40 hrs/wk)

*Qualification = 20+ minutes of care, signed PHI Authorization, has had a Care Plan shared

Activities that will result in 20+ minutes of quality care each month

Respond to messages (Inbox Zero within 48 hours)
Call patient to catch up (once monthly)
Conduct chart reviews for gaps in care, recent updates, etc.
Review and revise care plans and health goals ( Quarterly)
Plan and track progress to health goals with patient
Review the EHR for care activities performed by other team members, as these count towards CCM (Weekly on Friday AM)
Review the EHR to find and close any care gaps
Coordinate with your care team on any needs for the patient
Send 4-8 check-ins per month using the information learned from conversation or chart reviews as needed to engage all patients

Want to chat with someone about best practices? Contact support@phamily.com