Objectives

The Multidisciplinary Care Management team works collaboratively with the practices and primary care providers to provide care planning and care coordination for at risk patients.

Goals include:

  • Analyze chronic disease status, risk scores, utilization and cost to proactively identify patients needing care.
  • Develop personalized care plans for high risk, high need patients needing longitudinal relationship based care.
  • Provide targeted short-term (episodic) outreach and care management through a period of risk.

General Approach

Two Step Stratification

The team works with our data and practice transformation teams as well as practices to stratify patients by risk level using several data sources. These sources include the Hierarchical Condition Category (HCC) scores, Crisp Reporting System (CRS) Likelihood of Hospitalization Score (Pre-AH) and Covid-19 Vulnerability Index (CVI), as well quality and chronic disease data.

The process of collaborating with primary care providers who add clinical judgment to further adjust the risk level of their patients allows care management teams to predict the likelihood of negative health outcomes and target appropriate outreach and care plan development.

Longitudinal Care Management

Personalized care plans for high-risk, high need patients to proactively outreach on a regular basis and provide longitudinal, relationship-based care are developed. Patients often have conditions or situations with outcomes that can be modified through patient, provider, care manager collaboration and engagement. Those who can benefit from longitudinal care management include those with:

  • Complex Treatment Plans
  • Multiple comorbidities
  • High inpatient and emergency room utilization
  • Mental illness or behavioral needs
  • Complex medication regimens
  • Social risk factors influencing overall health

The team works collaboratively with patients and families, primary care providers, hospitals, specialists and community agencies to help coordinate care and services.

Episodic Care Management

The team will provide targeted short-term care management to support patients through a period of risk. This includes:

  • Brief disease management and health coaching
  • Outreach and education for new diagnosis
  • Medication reconciliation on transitions or for polypharmacy
  • Coordination and accurate information sharing during transitions of care (e.g. hospital to home, post-acute care settings)
  • Connection to community resources, transportation, specialty referral coordination
Referral Intake

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