Best Practice Corner: Anchor Medical Standardizes Patient Risk Stratification, Nurse Care Manager Assessment, Care Plan and Follow up Processes

Primary care practices are often challenged by creating consistent processes for stratifying patients based on risk status and using the electronic health record to develop and implement standardized nurse care manager assessment and care plan templates.

Marna Heck-Jones (information manager) and Kenny Correlia (pharmacist) shared the work that Anchor Medical has done to assist nurse care managers document the work they do with high risk patients.  Anchor used AAFP guidelines to define patient risk status and developed care assessment templates within Athena, the electronic health record (view the Care plan assessment document).  The care manager assessment template triggers the pre-configured follow up reminder between visits and the care plan template prompts the NCM to identify barriers, patient functional abilities and self-management goals. 

Anchor additionally developed a Training Guide (view training guide here) to assist staff with implementing these care manager tools.  Many thanks are extended to Marna and Kenny for sharing their great work at the June Practice Reporting Committee meeting.