NCCN’s Care Management Model works collaboratively with healthcare providers, hospitals, and community organizations. We utilize evidence-based practices, tools and resources to support patients, no matter where they are on the care continuum. We use a team of highly skilled and experienced interdisciplinary health care professionals to provide complex care management services to patients in conjunction with their primary care providers and specialists. We understand the significant role that social determinants of health have on health outcomes and costs. Our care team assures that the patient is connected with the right service and educated on how to navigate the health care system to meet those needs.
The goal of NCCN’s Care Management program is to work directly with patients, their family and natural supports, providers and community-based organizations to address systemic barriers to total wellbeing and brighter futures through appropriate and targeted care management interventions. We strive to assure that patients receive the right care, in the right setting, at the right time, in the most cost-effective manner. To achieve this, we conduct a comprehensive assessment and develop and implement a care plan with performance goals, monitoring and follow-up.
Our program is a collaborative process of assessment, planning, education, coordination, monitoring, and evaluation of services to meet the patient and their family’s comprehensive health and social needs. Within a framework of cultural competency and professional excellence, our program uses a patient-centered, holistic approach that encourages self-care, integrates behavioral change science and principles, ensures safe transitions, links community resources and assists with navigating the health care system. The program also promotes quality outcomes and has established periodic assessments to measure and track the outcomes.
The roles of the Care Managers are consistent with those outlined in the CMSA Standards of Practice: assessment, care planning, facilitation, coordination, monitoring, evaluation, and advocacy. The program also follows the care management process detailed in the guidelines: patient identification and selection, assessment and problem/opportunity identification, development of care plan, implementation of interventions, monitoring and evaluation of progress, and closure of case management services.
We are committed to respecting patients’ rights who are receiving care management services, including confidentiality, privacy, and security of personally identifiable health information.
We provide Patient Rights and Responsibilities documentation at enrollment into our care management programs and services. This includes but is not limited to; notification of privacy practices, complaint process, and being treated with courtesy and respect.
We safeguard protected health information from inappropriate release or disclosure by adopting policies and procedures that align with national, state, and local privacy practices, including but not limited to HIPAA Privacy Rule, HIPAA Security Rule, and HITECH Act.