Quality Alliance offers four targeted programs to improve outcomes for patients with chronic and complex health needs. Throughout these programs, nurse care coordinators and network navigators collaborate with primary care physicians to support high-risk patients, address barriers to care, and streamline navigation of the healthcare system.
TRANSITIONAL CARE MANAGEMENT (TCM)
The TCM program ensures continuity of care during transitions between healthcare and home settings. Once discharged from a hospital or facility, eligible patients are identified based on payer attribution and risk. Nurse care coordinators provide outreach and support for up to one month post-discharge, focusing on:
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Reviewing discharge instructions and medications, with an increased focus on ensuring patient understanding
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Assisting with scheduling appropriate follow-up appointments
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Assessing eligibility for additional population health management programs
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Identifying and resolving barriers to care
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Preventing readmissions
CHRONIC DISEASE MANAGEMENT (CDM)
The CDM program delivers short-term support to patients with a goal of improving the overall health of patients with chronic diseases. Patients for this program are identified based on payer attribution and risk, as well as by physician referral. Over three to six months, nurse care coordinators assist with:
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Setting patient and family goals for disease management (e.g., diabetes, heart failure, COPD, hypertension, kidney disease)
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Educating on health conditions and treatment options
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Ensuring understanding and adherence of prescribed medications
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Providing disease-specific dietary guidance
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Addressing barriers to care related to social determinants of health
CHRONIC CARE MANAGEMENT (CCM)
The CCM program provides long-term, comprehensive support for patients with complex needs, mirroring many of the same goals of the CDM program. The program includes in-depth assessments and ongoing assistance, with enrollment duration tailored to patient requirements.
NETWORK NAVIGATION
The network navigation program helps practices close care gaps and enhance patient outcomes. Focus areas include preventative screenings (colorectal, breast cancer) and chronic disease management (diabetes, blood pressure control). Outreach is conducted via phone and MyChart to facilitate scheduling and gap closure.