Designed to improve patient access, care coordination and illness management, Blue Cross and Blue Shield of Illinois (BCBSIL) has launched the first specialty intensive medical home (IMH) program in the state with the Illinois Gastroenterology Group (IGG), the state’s largest independent gastroenterology practice, according to BCBSIL.
The IMH specifically targets individuals needing treatment for chronic illnesses. In the BCBSIL/IGG specialty IMH, these are the highest risk, multi-chronic patients with Crohn’s disease, an inflammatory bowel disease that causes a high incidence of complications.
IGG has already developed its own care management tool, Project Sonar, to enhance communications with its IMH patients with Crohn’s disease. Patients enrolled in Project Sonar receive monthly secure communications, including sets of selected questions about their health status. The answers to the questions produce a “Sonar Score,” a numerical value which correlates with symptom intensity. The slope of this score is then plotted over time to reveal trends. This type of monitoring enables the physician to intervene earlier if necessary.
In the specialty IMH, a nurse care manager (NCM) does initial outreach to 200 patients identified as the most critically ill. The patients receive a call, letter or email inviting them to enroll in the program at no cost. At an initial intake visit with the patient, the NCM does an assessment of medical and psychosocial needs and develops an action plan. The NCM will monitor the patient’s progress against the action plan, assist with care coordination and offer resources. The NCM ensures care is connected to the physician.
Source: Blue Cross Blue Shield of Illinois (BCBSIL) , October 14, 2014
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