Migration to Enhanced Care Coordination Capacity for Bundled Payments and Risk Contracts

The huge challenge for providers with the current innovation in healthcare is that there is no one payer-provider contract and therefore, no one moment in which a care delivery system is aligned to manage the clinical and financial requirements and people involved in the contract. Consequently, an ACO or other integrated health system may move in “fits and starts” toward the capacity to manage multiple risk contracts/populations. CCM knows the roadmap for organizing and teaching care providers and case managers the mindsets and methods to coordinate care across levels of care. We understand how to engage both acute, chronically ill, and end-of-life patients and their families. We know how to customize their individual care while systematically raising standards of all patients, regardless of their payer source. Electronic Medical Records will take you a long way, but there are crucial skills and tools needed by the provider side to monitor and evaluate patient progress. Put another way, we know how to help progressive clients connect the concerns in the boardroom to the behaviors at the bedside. 

Deliverables:

  • Custom-designed Risk Tools
  • Custom-designed Continuum of Care Plans
  • Organization of CaseHubs ™ at the Emergency Department, Medical Home/Neighborhood, and the Patient’s Home.
  • Training for Patient Engagement Techniques
  • Development of Patient/Family Advisory Groups
  • Conducting Patient/Family Focus Groups

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