DOCSLIB.ORG

Chronic Care Management Services at a Clinical Medical Group

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Chronic Care Management Services at a Clinical Medical Group Walden University ScholarWorks Walden Dissertations and Doctoral Studies Walden Dissertations and Doctoral Studies Collection 2018 Chronic Care Management Services at a Clinical Medical Group Sharon Guccione Walden University Follow this and additional works at: https://scholarworks.waldenu.edu/dissertations Part of the Health and Medical Administration Commons, and the Public Health Education and Promotion Commons This Dissertation is brought to you for free and open access by the Walden Dissertations and Doctoral Studies Collection at ScholarWorks. It has been accepted for inclusion in Walden Dissertations and Doctoral Studies by an authorized administrator of ScholarWorks. For more information, please contact [email protected]. Walden University College of Health Sciences This is to certify that the doctoral study by Sharon Guccione has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made. Review Committee Dr. Robert McWhirt, Committee Chairperson, Nursing Faculty Dr. Tanya Cohn, Committee Member, Nursing Faculty Dr. Corinne Wheeler, University Reviewer, Nursing Faculty The Office of the Provost Walden University 2019 Abstract Chronic Care Management Services at a Clinical Medical Group by Sharon Guccione-Gantz MS, California State University, 2012 BS, Indiana University, 1978 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University November 2019 Abstract The purpose of this project was to design a chronic care plan using the chronic care management (CCM) framework to improve health services at lower healthcare costs. The practice-focused question explored whether the operationalization of the CCM model would impact progress toward the management of chronic illness for the target population of Medicare beneficiaries with 2 or more chronic illnesses in an urban acute care agency located in the western United States. The middle-range theory, logic rational plan model, Lewin’s change theory, and the CCM’s coordination care and collaborative care concepts were used to guide the project. Data were collected from nursing databases and government agencies. Nurses were significant to the CCM reform by supporting the elements for proactive care. Nurse practitioners can bill using the CCM codes, and clinical nurses can performed patient sensitive care. The social changes were patients with chronic illnesses realized a better quality of life at lower health costs. Chronic Care Management Services at a Clinical Medical Group by Sharon Guccione-Gantz MS, California State University, 2012 BS, Indiana University, 1978 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University November 2019 Dedication This project was dedicated to my beautiful granddaughter and handsome grandson. May they find reward and happiness with providing help and assistance to all people as their great grandmother, grandmother, and mother did. Acknowledgments A heartfelt thank you to the medical doctor, project manager, and the staff at the community clinic for all their support during this project. Table of Contents Section 1: Nature of the Chronic Care Management Project ...............................................1 Introduction ....................................................................................................................1 Topic, Nature of Topic, and Social Change ............................................................ 1 Problem Statement .........................................................................................................2 The Local Nursing Practice Problem ...................................................................... 2 Relevance of the Need to Address the Problem...................................................... 3 Significance for the Field of Nursing...................................................................... 6 Purpose ...........................................................................................................................6 Meaningful Gap-In Practice .................................................................................... 6 Practice-Focus Question ......................................................................................... 7 How Does the Project Propose to Address the Gap ................................................ 7 Nature of the Doctoral Project .......................................................................................8 Source of Evidence ................................................................................................. 8 The Approach to Organize and Analyze the Evidence ........................................... 8 Purpose Statement Connected the Gap to Anticipated Findings ............................ 8 Significance....................................................................................................................9 Stakeholders Potentially Impacted by the Local Problem ...................................... 9 Potential Contributions in Nursing Practice ......................................................... 10 Potential Transferability of the Program Plan ...................................................... 11 Describe Potential Implications for Positive Social Change ................................ 12 Summary ......................................................................................................................12 i Section 2: Background and Context ..................................................................................14 Introduction ..................................................................................................................14 The Practice Problem ............................................................................................ 14 The Practice-Focus Question ................................................................................ 14 Purpose for this Doctoral Project .......................................................................... 15 Preview Major Topics in the Section .................................................................... 16 Concepts, Models, and Theories ..................................................................................16 Concepts, Models, and Theories that Inform the Project...................................... 16 Primary Writings Synthesized .............................................................................. 18 Key Terms ............................................................................................................. 19 Relevance to Nursing Practice .....................................................................................21 History of the Broader Problem ............................................................................ 21 Current State of Nursing Practice and Advancing Nursing Practice .................... 22 Current Strategies or Standard Practices Used Previously ................................... 23 The CCM Program fills Gap-In-Practice .............................................................. 24 CCM Advances Nursing Practice ......................................................................... 25 Local Background and Context ...................................................................................25 Summary of the Local Evidence ........................................................................... 25 Institutional Context.............................................................................................. 26 Local Terms or Operational Processes ................................................................. 27 Describe State and/or Federal Context ................................................................. 27 Role of the DNP Student..............................................................................................28 ii Professional Context and Relationship ................................................................. 28 My Role in the CCM Program Plan ...................................................................... 28 My Motivation for the CCM Program Plan .......................................................... 29 Potential Biases and Manage of the Biases ........................................................... 29 Role of the Project Team .............................................................................................30 The Project Team .................................................................................................. 30 Communication with the Team Members ............................................................. 30 Evidence from the Project Team ........................................................................... 30 Timeline for Reviews ............................................................................................ 31 Summary ......................................................................................................................32 Section 3: Collection and Analysis of Evidence ................................................................33 Introduction ..................................................................................................................33 Problem and Purpose with Summarized Background and Context ...................... 33 Section 3 Preview ................................................................................................
Load more

Recommended publications
  • Effectiveness of Chronic Care Models for the Management of Type 2 Diabetes Mellitus in Europe: a Systematic Review and Meta-Analysis
    Open Access Research BMJ Open: first published as 10.1136/bmjopen-2016-013076 on 20 March 2017. Downloaded from Effectiveness of chronic care models for the management of type 2 diabetes mellitus in Europe: a systematic review and meta-analysis Brenda W C Bongaerts,1,2 Karsten Müssig,2,3,4 Johan Wens,5 Caroline Lang,6 Peter Schwarz,6 Michael Roden,2,3,4 Wolfgang Rathmann1,2 To cite: Bongaerts BWC, ABSTRACT et al Strengths and limitations of this study Müssig K, Wens J, . Objectives: We evaluated the effectiveness of Effectiveness of chronic care European chronic care programmes for type 2 diabetes ▪ models for the management This is the first systematic review providing a mellitus (characterised by integrative care and a of type 2 diabetes mellitus in comprehensive overview of studies that have Europe: a systematic review multicomponent framework for enhancing healthcare evaluated the effectiveness of multifaceted dia- and meta-analysis. BMJ Open delivery), compared with usual diabetes care. betes care programmes addressing all their com- 2017;7:e013076. Design: Systematic review and meta-analysis. ponents together, rather than separately. doi:10.1136/bmjopen-2016- Data sources: MEDLINE, Embase, CENTRAL and ▪ The focus in this systematic review was on 013076 CINAHL from January 2000 to July 2015. European multifaceted diabetes care programmes Eligibility criteria: Randomised controlled trials only, to meet the need for efficient and estab- ▸ Prepublication history and focussing on (1) adults with type 2 diabetes, (2) lished programmes to providing optimal chronic additional material is multifaceted diabetes care interventions specifically care due to the burden of increasing diabetes available.
    [Show full text]
  • Social Determinants of Health, the Chronic Care Model, and Systemic Lupus Erythematosus
    Hindawi Publishing Corporation International Journal of Chronic Diseases Volume 2014, Article ID 361792, 7 pages http://dx.doi.org/10.1155/2014/361792 Review Article Social Determinants of Health, the Chronic Care Model, and Systemic Lupus Erythematosus Edith M. Williams,1 Kasim Ortiz,1 and Teri Browne2 1 Institute for Partnerships to Eliminate Health Disparities, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Drive, Suite 103, Columbia, SC 29210, USA 2 College of Social Work, University of South Carolina, Columbia, SC 29208, USA Correspondence should be addressed to Edith M. Williams; [email protected] Received 4 November 2013; Revised 9 December 2013; Accepted 9 December 2013; Published 2 January 2014 Academic Editor: Mario Cardiel Copyright © 2014 Edith M. Williams et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Systemic lupus erythematosus (SLE) is a chronic inflammatory rheumatic disease that disproportionately affects African Americans and other minorities in the USA. Public health attention to SLE has been predominantly epidemiological. To better understand the effects of this cumulative disadvantage and ultimately improve the delivery of care, specifically in the context of SLE, we propose that more research attention to the social determinants of SLE is warranted and more transdisciplinary approaches are necessary to appropriately address identified social determinants of SLE. Further, we suggest drawing from the chronic care model (CCM) for an understanding of how community-level factors may exacerbate disparities explored within social determinant frameworks or facilitate better delivery of care for SLE patients.
    [Show full text]
  • Quality Improvement Program: Implementation of Chronic Care Management Services in An
    Running head: IMPLEMENTATION OF CHRONIC CARE MANAGEMENT SERVICES 1 Quality Improvement Program: Implementation of Chronic Care Management Services in an Affordable Care Organization Lori Duke, DNP, FNP-C Mississippi University for Women DNP II NU 800 Dr. Lorraine Gaddis May 9, 2017 Copyright © 2017 Lori Duke All rights reserved. No part of this work may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without author’s prior written permission. DEDICATION Philippians 4:13 “I can do all things through Christ which strengthens me.” I dedicate this project to my awesome family. I could not have made this journey without all of you. To my husband, Leslie, thank you for your love and encouragement over the years. I am grateful to my parents, Waymon and Shirley Samples. Your support has been greatly appreciated. Most of all, I would like to thank my beautiful daughter, Kaylee, for being so encouraging and supportive of me. I hope from watching my struggles during these last few years while I completed this degree that you have learned to always strive to be best that you can be in all things you do. Please remember to follow your dreams, always! ACKNOWLEDGEMENTS The author would like to express their appreciation to my advisor, Dr. Lorraine Gaddis, and project committee members, Dr. Shonda Phelon and Dr. Alena Lester. Without your support and guidance, this scholastic project would not have been possible. Thank you for helping mold me into a DNP-prepared advanced practice nurse.
    [Show full text]
  • CMHCB) Demonstration: the Health Buddy® Consortium (HBC
    The Centers for Medicare & Medicaid Services' Office of Research, Development, and Information (ORDI) strives to make information available to all. Nevertheless, portions of our files including charts, tables, and graphics may be difficult to read using assistive technology. Persons with disabilities experiencing problems accessing portions of any file should contact ORDI through e-mail at [email protected]. April 2011 Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: The Health Buddy® Consortium (HBC) Revised Final Report Prepared for Lorraine Johnson, Sc.D. Centers for Medicare & Medicaid Services Office of Research, Development, and Information 7500 Security Boulevard Baltimore, MD 21244-1850 Prepared by Nancy McCall, Sc.D. Jerry Cromwell, Ph.D. Kevin Smith, M.S. Carol Urato, M.A. RTI International 3040 Cornwallis Road Research Triangle Park, NC 27709 RTI Project Number 0207964.025.000.001 EVALUATION OF MEDICARE CARE MANAGEMENT FOR HIGH COST BENEFICIARIES (CMHCB) DEMONSTRATION: THE HEALTH BUDDY® CONSORTIUM (HBC) by Nancy McCall, Sc.D. Jerry Cromwell, Ph.D. Kevin Smith, M.S. Carol Urato, M.A. Federal Project Officer: Lorraine Johnson, Sc.D. RTI International* CMS Contract No. 500-00-0024 TO#25 April 2011 This project was funded by the Centers for Medicare & Medicaid Services under contract no 500-00-0024 TO#25. The statements contained in this report are solely those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services. RTI assumes responsibility for the accuracy and completeness of the information contained in this report. _________________________________ RTI International is a trade name of Research Triangle Institute.
    [Show full text]
  • Patient Self-Management Support Programs: an Evaluation
    Final Contract Report ______________________________________________________________________________ Patient Self-Management Support Programs: An Evaluation Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Contract No. 282-00-0005 Prepared by: RAND Health Santa Monica, CA Marjorie L. Pearson, PhD, MSHS Soeren Mattke, MD, DSc Rebecca Shaw, MA M. Susan Ridgely, JD Shelley H. Wiseman, BA AHRQ Publication No. 08-0011 November 2007 This report was prepared by RAND Health under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 282-00-0005). The views expressed in this report are those of the authors, who are responsible for its content. No statement in this report should be construed as an official endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. This document is in the public domain and may be used and reprinted without permission. AHRQ appreciates citation as to source. The suggested citation format is: Pearson ML, Mattke S, Shaw R, Ridgely MS, Wiseman SH. Patient Self-Management Support Programs: An Evaluation. Final Contract Report (Prepared by RAND Health under Contract No. 282-00-0005). Rockville, MD: Agency for Healthcare Research and Quality; November 2007. AHRQ Publication No. 08-0011. ii Acknowledgments The authors acknowledge and thank the following individuals who participated in interviews for this report. We are grateful
    [Show full text]
  • 1 CCM Diabetes Care Guide
    1 CCM Diabetes Care Guide Chronic Care Management Diabetes Assessment, Referrals and Resources Introduction This diabetes assessment, referral and resource guide was updated June 2012. The intent of this diabetes treatment guide is to provide evidence based practice guidelines, nursing assessment tools, client and caregiver education materials and journal articles with supporting evidence, for use with CCM clients. Based on the review of the data from predictive modeling and claims data, diabetes, and the management of diabetes is one of the primary diagnosis of our clients enrolled in the CCM program. Considering the scope of diabetes and the ability to impact the outcome of this chronic illness, this manual will provide useful information and resources for the nursing staff. As additional resources are used or new practices are recommended this guide can be updated. Diabetes Action Plan Clients enrolled in CCM with diabetes or pre-diabetes will be assessed for and offered a Health Action Plan. This plan may include: 1. The client identifying his or her diabetes care team 2. The client identifying his or her diabetes goals. 3. Testing and management of A1c (7 or less) 4. Testing and control of blood pressure. (130/80 or less) 5. Testing and management of cholesterol. (LDL 100 or less) 6. Following a diabetic food plan. 7. Getting physical activity. 8. Stop smoking. 9. Taking medications as prescribed. 10. Checking feet every day for skin changes. 11. Dental care twice a year. 12. Home blood glucose monitoring as recommended. The most difficult step for most clients to control diabetes is the first step; setting a goal, and then making a plan to meet that goal.
    [Show full text]
  • Managing Chronic Conditions. Experience in Eight Countries
    European on Health Systems and Policies MANAGING CHRonIC CONDITIONS Experience in eight countries Ellen Nolte, Cécile Knai, Martin McKee Observatory Studies Series No 15 Managing chronic conditions The European Observatory on Health Systems and Policies supports and promotes evidence- based health policy-making through comprehensive and rigorous analysis of health systems in Europe. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine. Managing chronic conditions Experience in eight countries Ellen Nolte Cécile Knai Martin McKee Keywords: CHRONIC DISEASE - prevention and control DISEASE MANAGEMENT DELIVERY OF HEALTH CARE - organization and administration DENMARK FRANCE GERMANY THE NETHERLANDS SWEDEN UNITED KINGDOM AUSTRALIA CANADA EUROPE © World Health Organization 2008, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Address requests about publications to: Publications, WHO Regional Office for Europe, Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest).
    [Show full text]
  • Acr23777 Am.Pdf
    Article type : Original Article Persistently Frequent Emergency Department Utilization among Persons with Systemic Lupus Erythematosus Jiha Lee, MD, MHS1, 2 Judith Lin, MD1 Lisa Gale Suter, MD1,3 Liana Fraenkel, MD, MPH1,3 1 = Yale University School of Medicine, New Haven, CT, 06520 2 = University of Michigan, Ann Arbor, MI, 48109 3 = VA Connecticut Healthcare System, West Haven, Connecticut, 06516 University of Michigan Department of Internal Medicine Division of Rheumatology 300 North Ingalls Building, Room 7C27 Ann Arbor, MI 48109-5422 Email: [email protected] Author Manuscript This is the author manuscript accepted for publication and has undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/acr.23777 This article is protected by copyright. All rights reserved Word count: 3719 (limit 3800) Financial Interest: Lee, J, None; Lin, J, None; Suter, L works under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures; Fraenkel, L, None. Research reported in this publication was also supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, part of the National Institutes of Health, under Award Number AR060231 (Fraenkel). Abstract Objective: To evaluate SLE patients who persistently frequent the ED to identify opportunities to improve outpatient care. Methods: We conducted a retrospective study of SLE patients who frequented the ED for ≥3 visits in a calendar year from 2013-2016. Persistent users met criteria for frequent use for at least 2 out of the 4 years, and limited users for 1 out of the 4 years.
    [Show full text]
  • Leveraging Chronic Care Management to Improve MIPS
    Leveraging Chronic Care Management (CCM) to Improve MIPS Performance Background The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaces the Medicare Sustainable Growth Rate (SGR), which was how CMS previously controlled the cost of Medicare payments to physicians. MACRA is aimed at strengthening Medicare access and improving physician payments, among other improvements. About RevUp Chronic Care Out of MACRA is the Quality Payment Program (QPP), which streamlines several pay-for-performance programs in the new Merit-based Incentive Payments Management System (MIPS) and provides incentive payments for participation in Advanced The RevUp technology, services, and Alternative Payment Models (APMs). Payment adjustments start out at +/-4% in analytics produce scalable, high-touch 2019 and increase up to +/-9% by 2022 and continue at that rate for several care models that enrich the patient- years after. provider experience and reduce the cost There are several factors that go into determining if a clinician is MIPS eligible in of care. The RevUp platform delivers real, 2017. Primarily, any Medicare Part B clinician billing more than $30,000 a year measurable improvements in health and delivering care for more than 100 Medicare patients a year is eligible, with outcomes and lowers healthcare costs. the exceptions being those clinicians that are newly enrolled in Medicare, below See more at: www.quatrishealthco.com the volume threshold, or already participating in an Advanced APM. MIPS essentially replaces the PQRS (Physician Quality Reporting System) and MU (Meaningful Use) criteria. Providers who, during at least 90 days, report 6 or more quality metrics (out of 271), document 4 or more practice improvement activities (out of 92), and fulfll at least 9 required measures for advancing care information (out of 15) may qualify for fnancial incentives and avoid penalties (e.g., 4% in 2017 for failure to provide at least 3 successive months of reporting).
    [Show full text]
  • Evaluation of Care and Disease Management Under Medicare Advantage Contract HHSM-500-2006-0009I/TO4
    The Centers for Medicare & Medicaid Services' Office of Research, Development, and Information (ORDI) strives to make information available to all. Nevertheless, portions of our files including charts, tables, and graphics may be difficult to read using assistive technology. Persons with disabilities experiencing problems accessing portions of any file should contact ORDI through e-mail at [email protected]. Evaluation of Care and Disease Management Under Medicare Advantage Contract HHSM-500-2006-0009I/TO4 Interim Report - FINAL Prepared for: Gerald Riley, Project Officer Centers for Medicare & Medicaid Services DHHS/CMS/OA/ORDI/REG/DRHPD 7500 Security Blvd Baltimore, MD 21244 Prepared by: L&M Policy Research, LLC Attn: Lisa H. Green, Ph.D. P.O. Box 42026 Washington, DC 20015 240.476.6663 [email protected] With subcontractor: Mathematica Policy Research, Inc. May 18, 2009 TABLE OF CONTENTS ACKNOWLEDGMENTS ........................................................................................................................................ III EXECUTIVE SUMMARY ...................................................................................................................................... IV LITERATURE REVIEW ............................................................................................................................................... V KEY INFORMANT INTERVIEWS ................................................................................................................................. VI
    [Show full text]
  • Chronic Care Management Toolkit Your Implementation Guide for Patients with Chronic Conditions
    Chronic Care Management (CCM) Toolkit Your implementation guide for patients with chronic conditions Chronic Care Management Toolkit Your implementation guide for patients with chronic conditions Thank you for using the Chronic Care Management (CCM) Toolkit. This guide is intended to help you and your team implement or expand CCM for your targeted patients with chronic conditions. You can either develop CCM processes with your own team, or you can use this guide to help you form a collaborative partnership between a physician practice and a local pharmacist. How to use this resource... 1. Review the Overview Section on pages four through six. Index a. The Challenge Overview 04 b. Solution c. Team Members The Challenge d. Requirements and Components of a CCM Program Solution Team Members 2. Identify your implementation team to develop your next steps. Requirements and Components of a CCM Program a. Your internal champion and team members b. Community Pharmacist option Implementation Strategies for a Successful CCM Program 07 3. Assess Implementation Strategies for Successful CCM Trial Maximize Your CCM Program - Collaborate with a Pharmacist 10 4. Choose individual Appendices for: Team Tools and Sample Templates 12 a. Team tools • Appendix A: Sample CCM Care Plan Template b. Easy-to-use templates • Appendix B: Sample CCM Workflow c. Supplemental CCM resources • Appendix C: Sample CCM Care Team Flow • Appendix D: General CCM Benefits 5. Contact HQIN for technical assistance: [email protected] • Appendix E: Pharmacy Partnership Checklist
    [Show full text]
  • Complex Care Management Program Overviews: General (PDF)
    COMPLEX CARE MANAGEMENT PROGRAM OVERVIEW Aetna Medicare Advantage Embedded Case Management Program INTERVIEWEE: R andall Krakauer, MD, FACP, FACR Summary Aetna has developed a Medicare Case Management Program for selected participating medical groups. This program enhances the effectiveness of case managers by managing multiple chronic illnesses, overcoming psychosocial barriers, and managing advanced illness by providing such services in close collaboration with participating physicians and their staffs. In most cases, the case manager is embedded in the physician office. The program focuses on Medicare Advantage patients and currently includes more than 75 collaborative relationships nationwide. In 2012, each case manager served an average of 1,000 patients, and the company served more than 100,000 patients total. Patient Identification Inclusion Criteria Members are prioritized based on risk and opportunity for care management. The program aims to identify members with advanced illness (for example, terminal illness) and chronic illness, as well as to identify opportunities to engage members in ways that will improve quality of care and reduce avoidable costs. Program inclusion criteria include: This program overview is part • Multiple admissions, readmissions, and emergency department (ED) visits of a series describing innovative • Depression diagnosis approaches to caring for complex • Presence of actionable gaps in care: drug interactions, and absence of a patients. Funded by the California record of treatment or testing normally associated with a diagnosis HealthCare Foundation, these • Predictive modeling, which identifies opportunities through monitoring of claims and transactions, and involves analysis of numerous factors overviews are the result of a national scan highlighting The program seeks case referrals from participating physicians through collaborative arrangements and other forms of outreach.
    [Show full text]