CARE COORDINATION AND TRANSITIONAL CARE MANAGEMENT (TCM)


 

PRIMARY CARE COORDINATION

Healthcare can be stressful and confusing to patients, especially when they have chronic diseases and complex health needs.  Our specially trained RN care coordinators work closely with primary care physicians to coordinate the care of high-risk patients, help them navigate the healthcare system, and solve complex issues.

Our nurses telephonically reach out to patients to identify limitations and barriers to successful disease management. They check medications and doses, ensuring the patients are taking their medications as prescribed and receiving refills. After the physician discusses goals for disease management, the nurse coordinator follows up to ensure adherence or assist with removing barriers. Our nurses, when indicated, may also meet with patients in the physician’s office.

Using the power of our clinically integrated network and advanced technology tools, we assess risk acuity. This allows our experienced staff to focus on the right patients at the right time, providing support when it is needed most. The goal is to help patients manage their disease, while reducing Emergency Department visits and hospital admissions.

We provide assistance with:

  • Helping patients understand their health conditions and treatment options

  • Providing educational materials and resources

  • Identifying needs and goals of patients and their families in managing chronic diseases such as diabetes, COPD, hypertension, chronic kidney disease, and heart disease

  • Reviewing medication lists

  • Coaching in lifestyle challenges, such as healthier eating and smoking cessation

  • Assisting patients with transportation and medication needs

  • Facilitating access and referrals to social and community resources, including mental and behavioral health resources

  • Review medications; help patient’s overcome barriers in obtaining medications

  • Eliminate discrepancies in medication administration

  • Review hospital discharge instructions

  • Verify and facilitate a follow up appointment with the patient’s primary care physician

  • Assess if patient would benefit from long-term care coordination

 
Contact our Physician Engagement team to learn how you can add care coordination to your Primary Care practice.

 

Quality Alliance Care Coordination

Initial Pilot: Pre vs Post Cost and Utilization Analysis

 
 
Pre
 
Post
 
Change
Healthcare Cost
$2,561
$1,760
-31.3%
Pharmacy Costs
$98
$83
-15.8%
Admits Per 1,000
1,371
798
-41.8%
Skilled Nursing Facilities Per 1,000
8,840
4,498
-49.1%
ER Cases Per 1,000
1,196
698
-41.7%
CAT Scans Per 1,000
2,305
1,470
-36.2%
MRI Per 1,000
729
386
-47%
Primary Care Visits Per 1,000
14,538
13,283
-8.6%
 
 
*Cost per member per month
 

TRANSITIONAL CARE MANAGEMENT (TCM)

When a patient transitions between care settings, communication is key to ensuring there is no disruption in the patient’s plan of care. TCM is the process of managing a patient’s transition from one level of care to the next. These patients are identified and assigned a 30 day readmission risk score through EPIC. All patients with a risk score greater than 20 are called by a transitional care coordinator. The goals of this outreach include: 

  • Review medications; help patient’s overcome barriers in obtaining medications

  • Eliminate discrepancies in medication administration

  • Review hospital discharge instructions

  • Verify and facilitate a follow up appointment with the patient’s primary care physician

  • Assess if patient would benefit from long-term care coordination