A True Partnership Patient –Primary Care Provider -CHNCT.

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Presentation transcript:

A True Partnership Patient –Primary Care Provider -CHNCT

What is Community Cares? Interdisciplinary Primary Care Teams o Improving Access o Educating and Supporting o Stabilizing with Resources o Preventing Avoidable Hospitalizations

Our Team Who is the “Face of CHNCT” o Clinical Education and Resource Role (APRN) o Care Managers (RNs) o CHNCT Clinical and Non-Clinical Experts o Social Worker / Human Service Specialist

Clinical Resource Role (APRN) Active on State and Government Committees Facilitate Communication & Close Critical Gaps Educational Process Subject Matter Expert Enhance Practice Capabilities Provide Clinical Program Support

Care Management Registered Nurses as a Clinical Resource o Meeting with Patients and Family Members o Collaborating with Primary Care Providers o Partnering with Clinical Staff o Pulling the Resources together

The Right Patient Identification Stratification Use of Predictive Modeling Channel to Medical Home Designated Interventions for High & Moderate Risk Patients Access Community Resources Develop Patient Safety Net

Services Provided Individualized Care Management Disease Management Education High Risk Case Management Behavioral Health Partnership Dental Services Preventative Eye Care

Group Forums Peer Education and Support Foster Socialization Empower Patients toward Self Management Enhance Patient / PCP / CHNCT Relationship

CHNCT’s Nurse Help Line 24/7 Access to Quality Clinical Care Experienced Registered Nurses Available in the Patient’s Language Directs Patients to Correct Level of Care Refers patients to appropriate clinical resources HELP LINE #

Practice Transformation Support Evidenced-Based Care Improve Medical Management Systems Focus on Improved Access Provide Comprehensive Data Reports Implement Clinical Tool Kits Enhance Practice Capabilities Extensive Patient Education Library Resources

Program Highlights Designated Clinical Liaison from FQHC “Face of CHNCT” on site at FQHC Private Consultations with Patients & Families Group Forums Triage to CM/DM Programs as Appropriate Develop Actions Plans that Work Resource Allocation

Outcomes Measurement Process o Outreach / Enrollment / Touches Clinical / Quality o Impacting Care Delivery o HEDIS Measures Utilization o Decrease in Acute Care Services Satisfaction Member – Practitioner