Because care management and coordination often defy traditional return on investment formulas, come budget time, AltaMed Health Services Corporation had to take a hard look at contributions of its multidisciplinary care team to the organizational bottom line.
Shameka Coles, AltaMed’s associate vice president of medical management, outlines seven key metrics presented to AltaMed’s CFO tying the coordinated care team to Altamed’s financial goals—data that ultimately secured funding for phase four of the coordinated care management initiative.
During a May 2015 webinar, A Comprehensive Care Management Model: Care Coordination for Complex Patients, now available for replay, Ms. Coles shared the key steps in development, rollout and evaluation of this care management model for AltaMed’s highest risk patients, a population that includes dual eligibles.
Length: 3:48 minutes
To help patients transition from a skilled nursing facility (SNF) to independent living, the Council on Aging of Southwestern Ohio visits high-risk patients at SNFs within 10 calendar days of admittance, explained Danielle Amrine, the council’s transitional care business manager. During an April 21, 2015 webinar, Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, Ms. Amrine described seven key questions to ask patients during the SNF visit, how field coaches assess the SNF patient’s risk for readmission to the hospital, and the council’s novel arrangement for completing the SNF visits.
The SNF visits are one component of the council’s multi-faceted home visits intervention, a participant in CMS’s Community-Based Care Transitions Program (CCTP).
During the 45-minute webinar, now available as an on-demand replay, Ms. Amrine shared the key features of the council’s home visits program, including visit scheduling, patient assessment, post-visit touch points and program evolution.
Length: 3:16 minutes