Table 1.

Care Manager Activities Contributing to Outcomes

Care Manager Activities	Description
1. Ensuring primary care physician (PCP) follow-up and contacting the PCP on behalf of patients	Ensuring that patients have a primary care physician and that follow-up appointments are scheduled within seven days of hospital discharge. Directly following up with primary care physicians when a patient has a question or experiences a problem.
2. Coordinating appropriate services	Ensuring appropriate referrals are in place and contact facilities such as a home health agency or pharmacy to follow-up on patients. Providing patients with contact information for outpatient or TOC3 care managers so that patients can contact them when needed. Scheduling follow-up appointment with a specialist for surgical patient, if necessary.
3. Providing patient education	Providing general education, education on medications, and education on signs and symptoms: e.g., weight gain for CHF4, continued shortness of breath for COPD5, and infection or bleeding for surgery). Teaching patients what to do if signs or symptoms occur. Asking patients whether they have any questions about their disease or condition.
4. Using health information technology	Using case management software, electronic health record systems, and a health information exchange.
5. Ensuring patients have proper equipment	Following up with clinicians and care facilities that provide patients with the required equipment.
6. Performing medication reconciliation	Reviewing list of medications and identifying any discrepancies.
7. Focusing on patients with higher need	Considering culture, education level, and psychosocial conditions of patients when managing their care.
8. Building relationships with patients	Making patients feel valued so that they know someone will follow-up with them after discharge.
9. Supporting or helping clinicians	Contacting doctors. Educating clinicians about the role of Keystone Beacon and the care managers. Identifying and following up on inaccuracies and omissions, and helping clinicians to achieve their goals (e.g., decreasing hospital readmissions).
10. Building trust with clinicians	Interacting with clinicians in order to build trust over time.