Patient Engagement

How to Build the Best Care Management Team for Your FQHC

A care management team might sound like a “nice-to-have” option at first glance, but in reality, they’re a powerful tool that can provide unmatched support for your patients and underserved communities — especially when it comes to effectively managing medical conditions in the age of value-based care.

In general, care management teams in FQHCs and RHCs end up dedicating a significant amount of effort to chronic care management, but also provide services including:

  • Transitional care management

  • General behavioral health integration

  • Psychiatric Collaborative Care Model

This team-based, patient-centered approach allows you to make tangible progress toward value-based targets and Triple Aim goals. It also helps you achieve better outcomes for your underserved communities — if you build your team the right way.  


Understand Your Role as a Provider to a Unique Demographic


If you work with underserved populations, your care management team will be meeting specific needs, both for your patients and your organization. This is especially true in your work with chronic care management, which puts teams in charge of addressing complex high-risk patients who often exhibit multiple comorbidities.

Take diabetes for example, since it’s so common in both urban and rural underserved communities. 98% of adult type 2 diabetes patients have at least one comorbid condition, and nearly 90% have two. Helping patients navigate health challenges of this nature takes a targeted approach.

This is why, from the beginning, you should consider the factors that make your goals and challenges unique.

Step 1: Start by Outlining Your Patient Mix and Local Demographics

Care management teams involve diverse groups of professionals interacting with patients on an individual and group basis.

Laying out the challenges, goals, and opportunities particular to your area will help you build a highly effective care management team. As recommended by the Healthcare Transformation Task Force, tailoring your team to specific patients is a key trait of a successful care management program.

Step 2. Identify Your Organizational Goals

Care management teams provide a unique opportunity to make practical progress toward some of your most challenging organizational initiatives.

Before you start any team-building, make sure you’re aware of your organization's objectives and existing initiatives so you can align your efforts. These might include financial health, adjusting patient behavior to value-based changes, attracting new professional talent, reducing ER admissions, and even rebranding initiatives to refresh your organization’s reputation within the community.

Start Building Your Teams

It’s time to start assembling your team!

Save this process as a guide for when you’re ready to start putting your care management team together.

Step 1. Outline Your Team Purpose

If you and your leadership want to see specific results and outcomes from your care management team, now is the time to solidify and document them.

For example, your team might be directly tasked with improving outcomes for hypertensive or HIV patients through better use of technology.

This should be clearly outlined and communicated to all present and future team members. Most importantly, make sure all members understand that their number one responsibility is to your patients.

Step 2. Look for Members

In general, core care management teams consist of the following members:

  • A behavioral healthcare manager (with formal education or specialized training in behavioral health such as social work, nursing, or psychology).
  • A psychiatric consultant (trained in psychiatry and qualified to prescribe a full range of necessary medications).
  • Auxiliary staff including pharmacists, care managers, social workers, nurses, community health workers, and physicians.

When considering these professionals, make sure they believe in the potential success of the care management team and are dedicated to achieving its goals.

Step 3. Consider Team Dynamics

Care management programs require frequent meetings and a sophisticated level of coordination and communication. You should consider your team’s purpose when deciding the meetings’ cadence, and also choose facilitators and set clear expectations for attending and participating in the meetings.

Physicians often serve as care management team leaders. They are tasked with handling conflict and potentially even feedback and review processes. Still, make sure you consult all team members when establishing group guidelines and standards.

Team dynamics have a direct impact on performance, so early efforts to understand and maximize them through investing in communication, cultural competency, and problem-solving skills can be a huge pay off in the long run.

Step 4. Think Tech

Your care management team is grounded in its people, and tech can make them even more effective. Take time to evaluate care management systems and don’t forget to talk to your existing vendors, especially your EHR partners. You may already have workable but unused care management functionality on the systems you’re using currently.

Keep in mind, though, that under the new requirements of value-based care, a naked EHR or care coordination solution isn’t enough. Invest a meeting or two in conversations with your tech teams about your needs.

Step 5. Prioritize and Empower Your Patients

Most importantly, focus on creating an ongoing conversation with your patients. Understanding how social determinants of health impact their healthcare decisions and outcomes is crucial for their success and your care management team’s progress.

One of the most effective ways to give patients more agency in directing their care is through a robust, tech-enabled goal setting program that supports their medical education, nutrition and exercise habits, and other desired behavioral changes. To optimize outcomes, this program should leverage the way they prefer to communicate. For example, underserved populations with complex chronic disease challenges prefer communicating via text message. You can learn more about text messaging in goal setting programs here.

A well-built care management team can become your most effective asset in navigating value-based care challenges for your underserved populations. Don’t miss out on the opportunity many other FQHCs have leveraged to their benefit.

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