Objective of Integrated Care Management A proactive, personalized, - PowerPoint PPT Presentation

Objective of Integrated Care Management A proactive, personalized, patient-centric approach . • Use of evidence-based practices. • Focusing on highly complex populations. • 1

Identification: Assessment and Stratification Top 5% of highest cost patients account for 50% of total costs • Costs are NOT primarily driven by end-of-life spending • Costs are NOT primarily driven by ED utilization • Patients spread across all major financial classes (i.e. not primarily an • uninsured issue) 2

Comprehensive Care Clinic An outpatient clinic that provides intensive medical, behavioral, and social management for high-risk patients Service Area: 30-mile radius of Intermountain’s • Flagship Hospital Model: Interdisciplinary team: medicine, nurse • care management, nutrition, social work, pharmacy, behavioral health, and pain services 3

Comprehensive Care Clinic: Process Acts like a primary care office with more resources • Ensure patients receive care in appropriate setting • Coordinate and collaborate with all of the patient’s specialists • Committed to eliminating all avoidable health care emergencies • 4

Community Care Management A community-based support team that provides intensive medical, behavioral, and social care coordination for high-risk patients. Service Areas: 30 mile radius surrounding 3 • of the largest regional medical centers Model: RN, LCSW, Transitionist, Pharmacists • 5

Community Care Management: Process In-home visits to understand environment of care • Connects patients to both Intermountain & community-based resources • Primary care • Homeless shelters • Mental health • Food security programs • Home Health • Pharmacy • Frequent follow-up & support • Care coordination to navigate complexities of healthcare system • 6

Comprehensive Care clinic Integrated Community Care Community Care Management

Integrated Community Care A single care model for highly complex patients • One high-cost patient clinic/program Avoids duplication of services and leverages strengths of both • programs Integrated medical management that integrates community partners • and services At home patient visits / assessments • 8

Integrated Community Care Team Flow Chart Qualified Person Identified Integrated Community Care Team (Triage/Assessment Team) Introduces program to patient • Transitionist Makes appointment • Assess patient at home • RN and SW Care Managers Have weekly case reviews with consultants • (Pharmacist, APRN, Physician Consultant) Pharmacist APRN Consultants participate in weekly case reviews • Physician Consultant Patient gets funneled out to correct community partners, with care plan in place. ICCT oversight/monitoring on-going. Community Partners IMG AP ML WMH FC SFCC CHC (CCC/Med Home) AP = IH Affiliated Providers CHC = Communityhealth Connect FC = Food & Care Coalition IH = Intermountain Healthcare IMG = Intermountain Medical Group IMGC = Integrated Care Management Guidance Council ML = Mountainlands Family Health Center SFCC = South Franklin Community Center WMH = Wasatch Mental Health