CaseHub™ Development for ACO's

Definition

A CaseHub™ is a centralized service in the continuum of healthcare services provided by health systems, payers, and Accountable Care Organizations, where the needs of patients and their families are assessed and triaged to the best place, level of care provider, or other resource for intervention/treatment. Specific patients might then be tracked/monitored for their achievement of desired and realistic outcomes of that care. Three of the most important CareHubs are the hospital Emergency Department, the Patient-Centered Medical Home, and the patient’s residence.

PurposeThe Center for Case Management provides Assessment, Design, Implementation Support, and Training to create a standardized operational system and clinical case/care managers for triage to the most precise, patient-specific care at the right time in the right place.  Depending on the level of clinical risk, selected patients will subsequently have their care coordinated, monitored and themselves be educated across time and place to ensure the achievement of clinical integration. (see definition below)

Results/Outcomes:

  • Reduce Cost per Case for specific patient populations through  evidence-based, CORE CLINICAL OUTCOME and PROCESS-driven care –individualized and choreographed for each person
  • Patient and/or family achievement of target level: 1) compliance, 2) adherence, or 3)self-management
  • Comply with federal, state, and local standards and regulations
  • Exceed patient and family expectations of the healthcare experience
  • Differentiate services and brand within local market

Components:

  • Clinical Integration for each patient/member through all transitions
  • Central Clinical Care/Case Management Professional:  RN, NP, SW, to lead and coordinate treatment teams and medical neighborhood
  • Patient/Family-version of Continuum Plan of Care/CareMap™
  • CareCalendar ™ of monthly appointments in the medical neighborhood as needed (PCPs, MD specialists, therapists, community resources)
  • CareGraph™  Clinical Progressions to guide transitions rather than proprietary criteria for medical necessity
  • The family is central in the health team
  • RoundingWell ™ contact, monitoring, and data software

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