Condition Management – Program Operations Jordan Plumbee
CCI’s Care Coordination Services supports the patient-provider relationship and plan of care, while emphasizing the prevention of disease progression and complications using cost-effective, evidence-based practice guidelines and patient empowerment strategies such as self-management tools. Clinical data sources are utilized to assess and proactively identify a patient that is living with or at risk for complex and/or chronic medical conditions. All data collected through the assessment process will be stored within the patient’s electronic health record (EHR) and will be utilized to place the patient into the appropriate risk category, thereby determining the level of involvement employed by Care Coordination Services staff. Patients are selected for Care Coordination Services through diagnosis complexity, identification of barriers to improved health, compliance with treatment plan and high use of resources. Patients receive Care Coordination Services in an effort to improve overall health status, improve satisfaction and improve efficient use of resources.
By participating in Condition Management, the patient agrees to work with their providers, as well as the Care Coordination Services staff. The patient must acknowledge and agree to a care manager or health coach reviewing medical and prescription drug claims, lab results, health risk appraisals, and EHR data to identity opportunities for prevention or intervention. The patient will be engaged by program staff at least once by phone. The exact frequency of these engagements will be determined by the patient’s risk level and preference.
Patients enrolled in Condition Management will primarily receive information regarding self-management actions by phone. All interactions will be documented in the patient’s EHR. A patient may, at any time, request a copy of this record. Formal recommendations, referrals for Care Coordination Services, and other services will initially be communicated by phone and will be documented in the patient’s EHR in the same manner as all other interactions. Upon enrollment, the patient will receive a self-management action plan with goals agreed upon by the patient and members of the healthcare team, including the patient’s primary care provider. Progress will be evaluated at every encounter, and a revised plan will be given to the patient and will be documented in the EHR.
In certain situations, incentives and discounts may be available to those with certain chronic conditions. Participation is voluntary and, if at any time the patient chooses to stop participating in the program, he or she may opt-out. The patient acknowledges that, if he or she chooses to opt out of the program, he or she will forfeit specified incentives and discounts.
Care Coordination Services abides by state and federal regulations that govern the disclosure of information to third parties. If information must be disclosed to third parties, the request must be obtained in writing and only the requested information will be transmitted. The patient will be informed within 72 hours by phone about the disclosure of information.