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A True Partnership Patient –Primary Care Provider -CHNCT.

Published byNathan Conley Modified over 8 years ago

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Presentation on theme: "A True Partnership Patient –Primary Care Provider -CHNCT."— Presentation transcript:

1 A True Partnership Patient –Primary Care Provider -CHNCT

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

3 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

4 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

5 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

6 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

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

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

9 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 # 1-866-803-7496

10 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

11 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

12 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

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