Population Health | ACOs | Ambulatory Care
- Expertise in Pop Health Management and Accountable Care Organizations
- Experts in connecting ACO’s with community resources to enhance pop health efforts
- Assist in developing pop health improvement programs such as disease management programs/care coordination programs
- Evaluate and assist in more robust Pop health infrastructure to enable care coordination across the community
- Evaluate and support addressing Pop health priorities unique to organization
- Support development and implementation of strategies to address cost and quality
- Expert in supporting improving Delegated & Managed Care ACO models: strategically and day to day operations
- Build integrated care management models and practices
- Relationship building with Payers and Health systems for improved care coordination
- Provide leadership, coaching and implement practices for Delegated models of care
CaseHubs™ for ACOs
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.
Purpose: The 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
90 day Bundled CareMap™
The Center for Case Management is the recognized founder and creator of CareMaps, first developed and implemented for clinical use in the 1980’s.
CareMap™ (tools) added clinical outcomes along with the necessary interventions for each phase/stage of care. Bundled payment methods are demanding a renewed interest in CareMaps as THE plan of care across levels of care for at least 90 days. The CareMap ™ that is developed will be a standard of practice on paper and a tool for use by the team, not the patient/family. CCM recommends that pictorial plans of care be given to patients, including phone numbers of key providers. Health Systems and ACOs will have to determine how each CareMap ™ will be computerized.
Note: The work of clinical case managers/care coordinators is to individualize each “best practice” CareMap ™ for each unique patient and caregiver/family situation, including comparing the prices per level of care.
Deliverables:
- CUSTOM-DEVELOPED 90 Day Bundled CareMap ™ tool: CCM can help you develop one CareMap ™ per day/diagnosis or population, which includes a license to use the trademark.
- Developed with the lead physicians and multidisciplinary teams across SNF, Home Health/Hospice, IRF, LTACH, Outpatient, etc. most involved with that diagnostic population
- Costs and days will be allocated to each level of care and/or interventions.
- MEASUREABLE OUTCOMES will be identified in 4 large categories:
- Health (mental and physical)
- Absence of complications most often found in that population
- Function (physical, work, role)
- Knowledge
- KEY INTERVENTIONS will be associated with each day/phase/stage/level of care in at least 9 different categories, including
- Assessment
- Tests/Monitoring
- Consults
- Nutrition
- Therapies
- Medications
- Safety
- Teaching
- Community Agencies
Enhanced CM - Risk Contracts
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
Whitepaper 1
Preview whitepaper on case management models
Whitepaper 2
Pediatric case management best practice standards
Whitepaper 3
Data essentials for any case management program