Evidence Based Care - ANSWER Helps us identify the most appropriate individualized treatment plan, improves patient outcomes, increase effectiveness and efficiency of interventions, and most current research and patient outcome measures

Empanelment - ANSWER The act of assigning individual patients to individual primary care providers (PCP) and care teams with sensitivity to patient and family preference. The basis for population health management and the key to continuity of care.

Strategic Partners Community Resources - ANSWER PCP. Outpatient clinics, Women's Health. Specialty care providers, therapists, pharmaceutical support, social workers

Accountable Care Organization (ACO) - ANSWER Improve patient outcomes through coordination of care measures and service that improve a patient's quality of life. Goal: reduce hospital readmission and improve patient compliance in community settings.

AIMS Care Coordination Model (PACO like TACO) - ANSWER Patient Engagement 

Assessment and Care plan Development 

Case Management 

Ongoing Care as Needed

Patient Engagement Phase PACO - ANSWER Interact

Ensure

Provide guidance and resources

Assessment and Care Plan Development Phase PACO - ANSWER Identify social and environmental factors that may affect medical plan adherence, health care serves utilization, and health care outcomes.

Collect information that is helpful 

Develop care plan

Case Management Phase PACO - ANSWER Patient stays on track and has the support 

Monitoring goal progress

Modifying the care plan as necessary