Improving PCP Referrals to Care Management Toolkit

Four steps to integrate primary care providers into care management

Integrating care management into the primary care work flow starts with strong relationships between primary care providers (PCPs) and care managers (CMs).

For many providers, the care management integration process proves challenging. Not all primary care physicians know about the benefits care management brings, and not every primary care practice has the technological infrastructure in place to make referring patients to care management easy.

Below, you'll find a toolkit to help facilitate collaboration between PCPs and CMs with four steps:

1. Structure a comprehensive onboarding process

2. Demonstrate and communicate the value of care management (available to Population Health Advisor members only)

3. Streamline PCP referral processes (available to Population Health Advisor members only)

4. Establish two-way feedback with PCPs (available to Population Health Advisor members only)



Step 1: Structure a comprehensive onboarding process

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. Implementing a standardized, system-wide education program is an important first step toward maximizing the value of care management in your primary care practice and achieving system-wide quality standards.

In this section, you'll find tools to help care management leadership design and implement an education program that aims to familiarize primary care physicians and staff with care management services and establish care managers as key members of the practice’s team.

Start by designing a curriculum that addresses key topics and lessons, then designate responsibilities for each member of the care team, and outline referral pathways for each staff member.

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Download the templates:

 Blank Onboarding Plan Template
Care management leaders can use this sample strategic plan to design their own strategy for onboarding primary care physicians and staff to their care management program.

 Sample Lehigh Valley Health Network Care Team Compact
Our sample agreement delineates job responsibilities of different primary care staff members to reduce redundancies in patient care and help all members of the care team hold each other accountable.

 Blank Referral Pathway Template
Our template provides a guide to outlining appropriate care management referral pathways for different members of your primary care practice staff.


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