Finalized Plan for Integrated Ambulatory Care Center (IACC)- Integration of Comprehensive Work

Finalized Plan for Integrated Ambulatory Care Center (IACC)- Integration of Comprehensive Work

Innovative solutions are needed to address the population’s shifting needs in the ever-changing healthcare environment. We put up a thorough approach that draws from numerous facets of healthcare management as we present the Board of Directors with the finalized plan for the Integrated Ambulatory Care Center (IACC). Our efforts throughout this capstone project have culminated in this plan, which covers everything from identifying the type of institution to adding quality measures that support our dedication to patient-centred care and operational excellence. In this proposal, we will go through the foundational tenets of the IACC’s concept once more, covering everything from the kind of facility and its offerings to the medical experts who will be its success determinants. In order to make sure that the facility functions effectively and places a priority on patient well-being, we will examine the nuances of reimbursement procedures and the integration of medical technology. Additionally, quality metrics and ethical and legal concerns will demonstrate our commitment to upholding the greatest levels of care and compliance. Do you need help with your assignment ? Reach out to us at eminencepapers.com.

Type of Facility

The suggested facility type is an Integrated Ambulatory Care Center (IACC) in response to the Washington, DC population’s changing healthcare requirements. Its capacity to provide comprehensive and patient-centred healthcare services on an outpatient basis, fostering ease, accessibility, and cost-effectiveness, supports this decision. The justification for advising patients to use an IACC is that it can provide a broad range of medical services under one roof, enhancing patient convenience and accessibility. The IACC strives to enhance patient outcomes and general community health by concentrating on preventative care, early intervention, and value-based care.

An ambulatory care facility offers more organized and coordinated healthcare than traditional inpatient institutions. With a focus on early detection and preventative care, the IACC hopes to lessen the impact of chronic illnesses on the community, thereby improving population health (Chiri et al., 2022). Because of the facility’s integrated design, different medical specialists can work together seamlessly, improving the continuity of treatment for patients. Additionally, the IACC may use telemedicine and technological innovations to deliver effective and accessible healthcare services, meeting the diverse needs of the Washington, DC, community.

Healthcare Delivery and Services

The Integrated Ambulatory Care Center (IACC) aims to provide the citizens of Washington, DC, with high-quality care and a wide range of healthcare services in an outpatient setting. Preventive care will be one of the IACC’s main areas of emphasis. To encourage early diagnosis and intervention, the facility will offer routine health examinations, screenings, and immunizations to delay the course of diseases and enhance general population health. The IACC will enable patients to adopt better lives, lowering the risk of chronic illnesses and improving their general well-being through health education and wellness activities. To effectively detect and treat various medical disorders, the IACC will also provide diagnostic services, such as imaging, laboratory tests, and speciality screenings (Kumaresan et al., 2022). Modern medical technology that enables precise and prompt diagnoses will benefit patients. In addition, the IACC will provide a comprehensive range of therapeutic services, including counselling, physical therapy, occupational therapy, and medical therapies, to treat acute and long-term disorders successfully. Patients will get individualized treatment programs that consider their medical needs using a multidisciplinary team approach.

Rehabilitation services will be an essential part of the IACC’s offerings, assisting patients in their journeys of healing and rehabilitation following surgeries or other medical treatments. To assist patients in regaining their functional independence and elevating their quality of life, the facility will hire qualified professionals, such as physical, occupational, and speech therapists. Additionally, the IACC will integrate behavioural health services to address mental health concerns and ensure holistic patient care, recognizing the interconnectedness of physical and mental well-being.

Staff at the Facility

Medical Providers

Physicians (MD/DO), nurse practitioners (NP), and physician assistants (PA) fall under this group. Physicians must be board-certified or eligible for certification in their fields, while NPs and PAs must hold current state licenses and certifications (Lee et al., 2019). These healthcare professionals will be crucial in diagnosing and treating patients, writing prescriptions, and managing care plans.

Nursing Staff

IACC’s nursing staff will consist primarily of registered nurses (RNs) and licensed practical nurses (LPNs). In Washington, DC, RNs must possess a current RN license and have successfully attended an accredited nursing program (Rapoza et al., 2022). The state will also require LPNs to obtain licenses. They will support the care of patients, the administration of medications, and patient education.

Diagnostic and Therapeutic Specialists and Administrative and Support Staff

This team will comprise a variety of experts, including occupational therapists, physical therapists, and radiologic technologists. As Washington, DC rules require, each specialist will need the relevant state licenses and certificates. The administrative and support employees category will include office staff, medical assistants, receptionists, and other support staff. These employees will be chosen based on their appropriate experience, qualifications, and dedication to patient care, even though particular qualifications may differ for various positions.

Reimbursement Methods

The landscape of medical care delivery in the United States is significantly shaped by reimbursement practices in healthcare. Fee-for-service (FFS) is a common approach in which healthcare providers are compensated for the services they offer patients (Han et al., 2022). As a result of rewarding healthcare organizations for carrying out more operations, tests, and therapies, this approach favors quantity above quality. While FFS permits detailed invoicing and offers clear financial incentives for providers, it might raise expenses and result in unneeded procedures.

Capitation is another kind of reimbursement that emphasizes population health management. With this system, healthcare professionals have compensated a certain sum for each patient they enroll, regardless of the services they offer. Since physicians are incentivized to keep patients healthy and limit expensive treatments, Capitation promotes preventative care and emphasizes cost-effective interventions. Given that healthcare providers have a financial incentive to maintain their patient populations healthy to increase income, this model encourages a more all-encompassing and integrated approach to healthcare.

Bundled payments, another name for package pricing, is a third reimbursement technique gaining popularity. In this case, a single payment is made to cover every service related to a certain medical condition or procedure. This approach promotes efficiency and cooperation by splitting a single payment among all the facilities and specialists engaged in a patient’s care. By coordinating incentives to deliver efficient and streamlined services, package pricing can result in higher quality care and lower costs.

Method Used for Facility

The ideal reimbursement strategy for the proposed Integrated Ambulatory Care Center (IACC), which is being developed in response to the changing healthcare needs of Washington, DC, is a blend of Capitation and package pricing. Given its focus on preventative care and early intervention, essential to the facility’s objectives, Capitation might be useful for the IACC. With Capitation, the IACC would be compensated a set amount for each enrolled patient, incentivizing the facility to concentrate on patient wellness and easing the burden of chronic illnesses on the local population. This approach supports the IACC’s mission to improve population health and foster wellness by offering regular physicals, screenings, and vaccines.

Furthermore, establishing package pricing for a few bundled services or processes could improve the accessibility and effectiveness of the IACC. The facility is well-suited for package pricing due to its integrated architecture and collaborative approach among various medical specialists. Services associated with particular ailments or treatments may be bundled to provide coordinated care, simplified procedures, and cost-effectiveness. (Silva, 2022) The cost of a comprehensive bundle of treatments should be made clear to patients upfront to encourage transparency and well-informed decision-making. Furthermore, the IACC’s use of cutting-edge medical technology to provide accurate diagnoses and administer rapid treatment aligns with the bundled payment strategy, guaranteeing patients receive comprehensive care for a single payment.

Pros and Cons

The mission of the IACC to provide complete and patient-centered healthcare services is well-aligned with Capitation’s emphasis on preventative care and holistic health management. This approach may lessen the burden of chronic illnesses on the community by encouraging healthcare professionals to prioritize wellness and early intervention. However, Capitation presents a challenge in precisely forecasting patient healthcare demands, which may lead to over- or overuse of services.

Bundled payments or package pricing may improve coordination and efficiency within the IACC’s integrated design. This approach promotes collaboration across many specialists and departments. It offers a single payment for a package of services associated with a particular ailment or treatment, resulting in streamlined and thorough care. Patients gain from upfront pricing clarity, which encourages rational decision-making. However, setting the right pricing for bundled services can take time, and there’s a chance that providers would cut corners on care to increase profits.

Impact of the Method

Adopting Capitation and package pricing reimbursement methods for the Integrated Ambulatory Care Center (IACC) could significantly impact its financial operations. Capitation might provide a more stable income stream, allowing for better budgeting and resource allocation (World Health Organization. Regional Office for Europe, 2022). Capitation poses problems if patient utilization changes greatly. Package pricing, on the other hand, can improve patient access to financial information and encourage coordinated treatment, which might result in cost savings through reduced procedures and better resource management.

Financial and Health Benefits

Integrating an electronic health record (EHR) system into the Integrated Ambulatory Care Center (IACC) has considerable cost and clinical advantages. EHRs minimize costs financially by streamlining administrative processes, cutting paperwork, and improving billing accuracy (Narikimilli et al., 2020). Improved data exchange and retrieval efficiency encourage more effective resource use. In terms of health, EHRs improve patient care by giving healthcare professionals easy access to a thorough patient history that helps them make wise decisions. Also, EHR interoperability promotes smooth specialist contact, resulting in coordinated care, less unnecessary testing, and improved outcomes.

Cost of Electronic Medical Records

Depending on the size of the healthcare facility, the complexity of the system, and the level of customization required, the initial implementation cost of an EHR system can vary dramatically. The initial implementation cost for a mid-sized ambulatory care facility like the IACC may range from a few hundred thousand to a few million dollars. This includes costs for staff training, hardware infrastructure, software licensing, data migration, and system customization to meet the needs of the IACC. Over the long run, the ongoing management and maintenance of the EHR, including software updates, security measures, technical support, and staff salaries for IT personnel, can contribute to a substantial recurring cost, often estimated at around 15-20% of the initial implementation cost per year. However, these investments can lead to significant operational efficiencies, improved patient care, and long-term cost savings, making the management cost a worthwhile expenditure for the IACC to ensure its continued success and effective healthcare delivery.

EHR Security Concerns

EHRs and HIT (health information technology) are currently the subject of security concerns due to patient data being susceptible to cyberattacks, unauthorized access, and data breaches. The potential of hostile actors attacking EHR systems to steal patient records or launch ransomware attacks has increased as the healthcare sector increasingly relies on digital platforms to store sensitive medical information (Singh & Madaan, 2022). Healthcare organizations must invest in solid cybersecurity measures, such as encryption, multi-factor authentication, regular system audits, and employee training, to prevent security breaches that could jeopardize patient confidentiality, disrupt healthcare operations, and erode public confidence in the healthcare system. Ensuring the privacy and integrity of patient data is essential.

Decision-Making

EHRs support well-informed choices and efficient problem-solving in the healthcare industry. EHRs enable healthcare professionals to examine a patient’s medical history, prescriptions, lab results, and treatment plans, facilitating accurate diagnoses and individualized care (Jha, 2023). This is done by giving them complete and real-time access to patient data. EHRs also help improve care coordination between professionals, facilitating group problem-solving for challenging cases. Clinical results and patient safety can be improved using data analytics and clinical decision support technologies integrated into EHRs to spot trends, warn about possible drug interactions, and recommend evidence-based treatment alternatives. Moreover, EHRs contribute to quality improvement initiatives by tracking and analyzing performance metrics, patient outcomes, and population health data, enabling healthcare organizations to identify areas for enhancement, optimize resource allocation, and implement proactive measures.

Federal Legislation – Technology

A landmark piece of federal legislation, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, has a significant impact on the use of EHRs and HIT by establishing extensive privacy and security regulations for protected health information (PHI). HIPAA mandates that covered entities, such as healthcare providers, health plans, and clearinghouses, maintain administrative, technical, and physical protections to protect patient privacy, limit unauthorized access, and secure PHI (McConomy & Leber, 2022). Additionally, it requires hiring a privacy officer, creating privacy policies and procedures, employee training, and signing business associate agreements with outside parties handling PHI. Additionally, HIPAA introduced the Privacy Rule, which grants patients control over their health information, and the Security Rule, which sets standards for electronic PHI security. The legislation emphasizes the need for secure data transmission, access controls, and regular risk assessments.

Accreditation, Certification, and Licensure – Facility

The legal procedure through which a healthcare facility receives authorization from a government body, usually a state or local authority, to run and offer particular medical services is called licensing. By being licensed, a facility can demonstrate that it complies with minimal legal requirements for infrastructure, staffing, safety, and healthcare quality. Healthcare facilities must adhere to legislative requirements to provide patient treatment. An individual’s skills and competence in a particular area of medical practice are recognized by certification (Wyman et al., 2019). To prove their competence and knowledge, healthcare professionals must go through certification procedures frequently handled by professional organizations or boards. A healthcare professional’s capacity to deliver specialized care within their sector is confirmed by certification. Accreditation is a voluntary process by which healthcare facilities seek external validation of their adherence to specific industry standards and best practices. Accrediting organizations, often independent bodies, assess a facility’s quality of care, patient safety protocols, organizational policies, and overall performance against predetermined benchmarks

Licensure and Accreditation – Providers

There are two regulatory procedures for healthcare professions or providers: licensure and certification. To ensure that practitioners adhere to certain education, training, and competency criteria, licensure entails gaining official permission from a government entity, generally at the state level (Rottman et al., 2023). On the other hand, certification is a voluntary process carried out by professional organizations or boards that verifies a person’s specific knowledge and ability in a certain healthcare field. Although certification shows a practitioner’s dedication to improving their knowledge and abilities to deliver specialized and high-quality care, licensure is still legally required to practice.

Ethical and Legal – Organization

A healthcare company has an ethical and legal duty to make sure that its facility is accredited, certified, and licensed in Washington, D.C. A facility must achieve minimal requirements for safety, staffing, and care delivery to maintain its license, which necessitates compliance with local and state legislation (Thobejane, 2023). Obtaining a license ethically represents a commitment to giving patients competent, safe care. The organization must hire certified practitioners who uphold the highest standards of practice, even if certification primarily focuses on individual professionals. Following industry best practices and quality standards is a requirement for accreditation, demonstrating the organization’s commitment to ongoing advancements in patient care, safety, and general performance.

Ethical and Legal – Healthcare Professionals

The healthcare business is required by law and ethics to ensure all its employees have the necessary licenses and certifications. Employing specialists who have met the demanding requirements set by licensing organizations and certification boards, indicating a commitment to competent and proficient care delivery, demonstrates the organization’s ethical obligation to prioritize patient safety and quality of care (Potter et al., 2021). To legally comply with state laws and safeguard patient rights, one must adhere to licensing and certification standards. The business ensures that its workforce has the skills and expertise required to deliver specialized care by confirming and maintaining its employees’ licensure and certification status. This also helps to develop a reliable and respectable healthcare environment.

Federal Legislation – Organization

The Joint Commission is one accrediting authority that could grant the planned healthcare facility accreditation. The Joint Commission, originally known as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO, was founded in 1951 and is a non-profit organization devoted to enhancing patient safety and healthcare quality (Mahadevan, 2022). Hospitals, ambulatory care centres, behavioural health groups, home care agencies, and long-term care institutions are just a few of the healthcare facilities it accredits. Through its stringent certification criteria and assessment procedures, the organization has significantly improved the standard of healthcare in the United States. The Joint Commission encourages healthcare facilities to embrace best practices, follow patient safety regulations, and uphold high standards of care by supporting evidence-based methods and continuous improvement. Its accreditation signifies a commitment to providing safe and effective patient-centred care and has contributed to raising the overall quality of healthcare services across various settings in the country.

Quality Measures

Patient satisfaction surveys and clinical quality indicators will be implemented in the proposed Integrated Ambulatory Care Center (IACC) as two important metrics to assess healthcare quality. Patients’ experiences, opinions, and satisfaction levels with the care and services received at the facility are gathered through patient satisfaction surveys. Surveys are crucial for comprehending patient viewpoints, pinpointing areas that require development, and developing patient-centred services (Ezzati et al., 2022). The IACC can improve patient-centred care and better communication and swiftly address any concerns by constantly assessing the findings of these surveys. By actively incorporating patient feedback from satisfaction surveys into the decision-making process, the IACC can foster a culture of continuous improvement, ensuring that patient needs and preferences remain at the forefront of their healthcare delivery approach.

Clinical quality indicators are another essential metric that will be used to evaluate the calibre of care offered at the IACC. These evidence-based measures represent the efficacy, security, and results of clinical interventions and procedures. Rates of hospital-acquired infections, prescription errors, readmissions of patients, and compliance with evidence-based clinical standards are a few examples of clinical quality indicators. The IACC can pinpoint improvement opportunities, put evidence-based best practices into practice, and guarantee that patients receive safe, efficient, and high-quality care by closely monitoring and examining these indicators. These actions add up to a comprehensive strategy for ensuring the quality of and enhancing the healthcare services offered by the IACC. By diligently monitoring and analyzing clinical quality indicators, the IACC can proactively identify areas for enhancement, implement evidence-based interventions, and maintain a commitment to providing exceptional patient care, thereby demonstrating a dedication to achieving and maintaining high standards of clinical excellence and patient safety

Data Collection and Analysis

Data for the identified quality measures, patient satisfaction surveys, and clinical quality indicators will be collected through a combination of methods. Patient satisfaction surveys will be administered to patients following their visits through paper surveys or electronic platforms, gathering feedback on various aspects of their experience. The collected data from the survey will be analyzed to identify trends, areas of improvement, and patient preferences (Carfora et al., 2022). For clinical quality indicators, electronic health records (EHRs) will be vital in collecting relevant clinical data, including outcomes, adherence to protocols, and safety measures. This data will be regularly reviewed and analyzed, enabling the IACC’s healthcare professionals to track performance, assess the impact of interventions, and make data-driven decisions to enhance clinical quality and patient safety. Regular audits and assessments ensure that the data collection processes remain accurate and comprehensive, facilitating continuous improvement in healthcare services (Chen et al., 2019).

Benchmarks

A reasonable goal for patient satisfaction surveys may be maintaining an 85% or higher overall satisfaction rate. This benchmark is founded on the knowledge that, even though individual variations make it difficult to achieve 100% satisfaction, aiming for a high satisfaction rate shows a steadfast commitment to patient-centred care and ongoing progress. Regarding clinical quality indicators, milestones include obtaining a prescription mistake rate under 2% and a 20% decrease in hospital-acquired infection rates during the next year. These standards match industry norms and evidence-based practices to dramatically enhance patient safety and quality results. By setting these realistic benchmarks, the IACC aims to ensure substantial improvements in patient experience and clinical care while recognizing the complexity of healthcare delivery and the gradual nature of change implementation. These benchmarks serve as guideposts for the IACC’s continuous efforts to deliver exceptional patient-centred care and maintain high clinical standards, reflecting the facility’s commitment to measurable progress and enhancing healthcare quality over time.

Part 2 – Reflection

My healthcare management degree and completing this course have given me a solid foundation in several key skills and competencies. I now thoroughly understand quality control procedures, healthcare delivery strategies, and the challenges of running medical institutions. My analytical skills have also improved, and I have learned how to assess healthcare data to make wise decisions that improve patient care and operational effectiveness. My courses have strongly emphasized communication and teamwork, which have helped me work well with various healthcare experts and tackle difficult problems in interdisciplinary settings. I have also learned about ethical issues in healthcare management, focusing on the value of patient-centred care, regulatory adherence, and upholding the highest standards of honesty.

I recognize a number of abilities and talents that need to be further developed as I start to advance my career in healthcare administration. Strategic leadership is one important area where I want to improve my capacity for developing and implementing novel plans that can be adjusted to the changing healthcare environment. Understanding healthcare policy trends, foreseeing market shifts, and promoting organizational resilience are required to achieve this. Additionally, I intend to use cutting-edge data analysis methods to draw out useful information from complicated healthcare data and support evidence-based decision-making. It will be vital for me to expand my understanding of healthcare technology and how it is integrated into operations to effectively use digital solutions for better patient care and administrative efficiency. Continuous learning will be a cornerstone of my development, involving staying updated on regulatory changes, emerging healthcare technologies, and best practices through workshops, seminars, and networking opportunities. By investing in my growth, I aim to contribute meaningfully to advancing healthcare management and positively impacting patient outcomes and organizational success.

Conclusion

As a result of all of our work, this final plan for the proposed Integrated Ambulatory Care Center represents a comprehensive strategy for healthcare administration. We now have a thorough understanding of the many different aspects that influence efficient healthcare delivery and management thanks to our experience working on this capstone project. The abilities we have developed throughout this process will form the basis of our profession in healthcare administration as we go forward. The depth of our approach is highlighted by the IACC’s dedication to patient-centred care, focus on utilizing technology to improve clinical results, and commitment to ethical and legal compliance. We emphasize the value of continual improvement and data-driven decision-making in healthcare by including quality measurements in our proposal. We understand that there is a need for continuous growth and development as we enter the field of healthcare management. The healthcare industry is dynamic, being changed by changes in patient expectations, laws, and technology. We are dedicated to further developing our strategic leadership abilities, mastering healthcare technology, and keeping up with the most recent business trends in order to successfully navigate these hurdles. Through this dedication, we hope to achieve not only professional success but also to meaningfully advance healthcare management and improve patient outcomes.

References

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Chen, H., Yu, P., Hailey, D., & Cui, T. (2019). Identification of the essential components of quality in the data collection process for public health information systems. Health Informatics Journal, 26(1), 664–682. https://doi.org/10.1177/1460458219848622

Chiri, G., Bergey, M., & Mackie, T. I. (2022). Deserving but not entitled: The social construction of autism spectrum disorder in federal policy. Social Science & Medicine, 301, 114974. https://doi.org/10.1016/j.socscimed.2022.114974

Ezzati, A., Davatzikos, C., Wolk, D. A., Hall, C. B., Habeck, C., & Lipton, R. B. (2022). Application of predictive models in boosting power of Alzheimer’s disease clinical trials: A post hoc analysis of phase 3 solanezumab trials. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 8(1). https://doi.org/10.1002/trc2.12223

Han, Z., Arikan, M., & Mallik, S. (2022). Competition between hospitals under bundled payments and fee-for-service: An equilibrium analysis of insurer’s choice. Manufacturing & Service Operations Management. https://doi.org/10.1287/msom.2021.1039

Jha, Y. K. (2023). Development of a centralized electronic medical record system – in HealthCare & Governance. Social Science Research Network. https://doi.org/10.2139/ssrn.4477097

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You have been asked to present your plan for the proposed healthcare facility to the Board of Directors. Based on your previous assignments, you are to develop a proposal as a written paper that includes the following:

The type of healthcare facility (Week 1)
Discuss the type of facility that you are recommending and the rationale behind your recommendation. For example, if you chose an ambulatory care facility, explain the reasons why this type of facility would be recommended over another type.
Discuss the type of health care delivery and services that are provided at the facility.

Discuss the type of staff that will work in the facility. Specify the position categories and/or titles for these positions and include what are the credentials or licensures required by these positions in the state in which you live where you proposed facility would be located.
Financing the organization (Week 2)
Discuss the method(s) of reimbursement that you believe will work best for the health care facility that you have proposed to be developed, and explain why you chose that method.
Discuss the pros and cons of the reimbursement method(s) you chose.
Discuss the impact that the method(s) may have on the financial operations of the facility that you chose.
Medical technology (Week 3)
Discuss the financial and health benefits that can be realized by implementing an electronic health record (EHR).
Discuss the estimated cost of implementing an EHR and the estimated cost of managing an EHR over the long run.
Discuss current security concerns surrounding health information technology (HIT) and the EHR.
Discuss how electronic health records can be used for decision-making and problem-solving.
Choose 1 piece of federal legislation, e.g., HIPAA, HITECH Act, Meaningful Use), and discuss the requirements that legislation imposes on the use of HIT and the EHR.
Ethical and legal considerations (Week 4)
Discuss an accrediting body that will provide accreditation to the facility you are proposing.
Discuss the ethical or legal requirements and responsibilities that a healthcare organization has in ensuring that its facility is licensed, certified, and accredited. When discussing licensure requirements, ensure that you research requirements based on the state in which you reside.
When discussing licensure requirements, ensure that you research requirements based on the state in which you reside.
Quality measures (Week 5) (This will be a new section as part of your project)
Research and describe at least 2 measures that you plan to use in your facility that are currently used to gauge quality in health care.
Identify how data for these measures will be collected and analyzed.
Set realistic benchmarks for each proposed measurement, and explain the rationale behind the benchmarks that you set.
Note: You should include a minimum of 3 references with the new content for Week 5 combined with the references used for the work done in Units 1-4.

All sources should be cited using APA format.
Grammar, spelling, punctuation, and format should be correct and professional.
Part 2: Reflection on what you have learned and what you will work on to continue to develop as a healthcare management professional. Write a 1-page reflection on the following:

As you complete the course and your degree program and look forward to advancing your career in healthcare management, what are the skills and competencies that you feel you have developed and what are the ones that you will need to continue to work on? How do you plan to improve upon your skills and continue to develop competencies in healthcare management?
The American College of Healthcare Management provides resources related to the competencies that healthcare management professionals should possess. Refer to this document for a list of healthcare management competencies.