ABSTRACT
This chapter presents an advanced care management concepts and framework and analyses key advanced care management components of the care management platform and focuses on the future of care management for population health management. The care team must be engaged with the patient to develop a plan of care using evidence-based pathways and protocols. Embedded rules-based workflows ensure the patient gets the right care at the right time and place. Effectiveness of care is measured on a regular basis not only to evaluate performance but also to identify areas for improvement. The greatest challenge for future advanced care management models will be to help patients with both high-acuity health challenges and low health literacy become low-acuity, highly health literate populations. The care management platform advanced care management layer will support a focus on chronic care management over the next decade while also taking important steps to prevent and reverse the conditions simultaneously.
