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An Approach to Care Management for High-Risk Patients: Page 2 of 3

An Approach to Care Management for High-Risk Patients: Page 2 of 3

Step 3: Engage the patient in an action plan for changes to a condition

To help prevent future hospitalizations, ER visits, and other health complications, it's important to educate the patient and any caregivers so they can identify the signs of an emergency or decline in health. Arming patients with this knowledge helps them take charge of their own wellness. During appointments, consider discussing the following topics with both patients and caregivers, and offer them educational materials for in-home use to reinforce the information regarding:

• How to make same-day appointments

• Where to go for after-hours urgent care

• How to tell the warning signs of heart attack, stroke, and other serious conditions for which they may be at risk

• When to call for help and whom to call

• Which hospital you prefer to use when time permits a choice of facility

• When to use emergency care

Step 4: Connect with medical and social support services

Some proportion of your Medicare population will need services outside the scope of traditional primary care to help them and their caregivers properly manage specific health conditions. To coordinate holistic care for elderly or fragile patients your practice may need to engage outside services to:

• Ensure that patients with complex medical conditions consult periodically with specialists

• Refer to case management services when medically indicated

• Refer to home health services as needed

• Make referrals to local social services

• Discuss palliative care options and advance directives with patients who have limited life expectancy

• Engage the patient's caregiver in these discussions and care plans


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