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The practice establishes a systematic process and criteria for identifying patients who may benefit from care management. The process includes consideration of the following:
4.A.1 Behavioral health conditions.
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4.A.2 High cost/high utilization.
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4.A.3 Poorly controlled or complex conditions.
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4.A.4 Social determinants of health.
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4.A.5 Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver.
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4.A.6. The practice monitors the percentage of the total patient population identified through its process and criteria. CRITICAL FACTOR)
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