Care Transformation Center Blog

The first step toward engaging PCPs in care management

Not all primary care physicians understand the responsibilities of care managers, the services they provide patients, or the benefits they bring to a primary care office.

In order to maximize the value of care management in your primary care practice and achieve system-wide quality standards, care management leaders should first aim to implement a standardized, system-wide education program. This education program should be geared toward familiarizing primary care physicians and staff with care management services and establish care managers as key members of the practice's team.

Proactive orientation

The onboarding process for PCPs who are new to care management should ensure PCPs understand care management services and processes and aim to secure buy-in.

Care management leaders at Lehigh Valley Health Network (LVHN) redesigned their initial orientation to clearly communicate the purpose of care management. They wanted to clarify expectations after experiencing resistance to care management integration from some providers and clinic staff.

LVHN's care management team requires all providers working with the program to participate in an initial orientation led by the Director of Population Health. In addition, all providers must agree to work with care management; if even one provider in a clinic objects to the program, the care management team will not allocate resources to that clinic.

As a final step, physicians sign an agreement confirming they understand the services that care management staff will provide as well as their obligations to work with care management staff to ensure the success of the program.

Ongoing education

After conducting the initial care management orientation, care management leaders should implement ongoing, multi-faceted education to fully educate PCPs about the care management program and referral processes.

Patient-centered medical home leadership and the residency program at Legacy Medical Group-Emanuel Clinic designed two comprehensive onboarding processes for new primary care residents and faculty. First, all new hires attend a formal orientation led by the Medical Director or a senior faculty member. New hires also receive flow charts describing care management referral pathways.

Following the initial orientation, new residents participate in daily 20-minute huddles for the duration of their residency where residents and the care management team discuss patients together. These huddles educate residents about care management and serve as a feedback loop to help refine patient referrals and improve patient care.

New faculty work with an experienced faculty mentor to guide their overall onboarding, including how to refer patients to the program. Mentors receive compensation for time spent working with new faculty.

For more insights on this topic, our toolkit for taking these first steps, and more Population Health Advisor resources to help you integrate care management in primary care, please feel free to email me, and be sure to check out the next post in this series.

How to design and implement an education program


Download Part 1 of our toolkit on improving PCP referrals to care management, complete with a sample care management onboarding plan and a template for outlining care management referral pathways, so you can start building your comprehensive onboarding process today.