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

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

Comprehensive Care Clinic

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

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
• f the largest regional medical centers
• Model: RN, LCSW, Transitionist, Pharmacists

Community Care Management

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 Community Care Management

Integrated Community Care

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

Patient gets funneled out to correct community partners, with care plan in place. ICCT oversight/monitoring on-going. Qualified Person Identified

IMG

(CCC/Med Home)

ML WMH FC AP

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

SFCC CHC

Integrated Community Care Team

(Triage/Assessment Team)

Transitionist

• Introduces program to patient
• Makes appointment

RN and SW Care Managers

• Assess patient at home
• Have weekly case reviews with consultants

(Pharmacist, APRN, Physician Consultant)

Pharmacist APRN Physician Consultant

• Consultants participate in weekly case reviews

Community Partners