The AltaMed multidisciplinary care team targets dual eligibles with multiple chronic conditions and functional and cognitive impairments.
When the largest FQHC in the country set out to quantify the contributions of its multidisciplinary care team, it found the concept didn't fit neatly into return on investment models.
So at budget time this year, leaders of AltaMed Health Services Corporation's care coordination model for its highest risk patients identified seven performance metrics to present to its CFO, explained Shameka Coles, AltaMed's associate vice president of medical management, during A Comprehensive Care Management Model: Care Coordination for Complex Patients, a May 2015 webinar now available for replay.
The evidence that ultimately secured funding for the care coordination project's next phase included the model's impact on specialty costs, emergency room visits, and HEDIS® measures, among other factors.
These were all areas examined early on, back in phase one, when the care coordination team set a number of strategic goals that aligned with the corporation's five pillars: service, quality, people, community and finance.
Rolled out in four phases beginning in July 2014, the model is aimed at AltaMed's dually eligible population— Medicare-Medicaid beneficiaries with high utilization, multiple chronic conditions, and multiple functional and cognitive impairments, Ms. Coles explained.
Phase one of the project was devoted to understanding and engaging the duals population via telephonic and print outreach, then developing a care management model reflecting both Triple Aim and patient-centered medical home goals. (The 23-site multi-specialty physician organization in Southern California has earned Joint Commission primary care medical home designation.)
At the heart of the model is a multidisciplinary care team, which counts a care coordinator, clinic patient navigator and care transitions coach among its eleven roles. Patients are stratified as high, moderate or low risk and matched to risk-appropriate interventions.
"Each member is activated based on where the patient is at in the continuum of care," noted Ms. Coles, who also reviewed team member roles and responsibilities and a host of complementary programs supporting care coordination during the May 2015 program sponsored by the Healthcare Intelligence Network.
In phase two, focused on development of end-to-end workflows, staff assessments and ratios, and team training, AltaMed hired an educator, fleshed out the patient navigator role, and examined integration of behavioral health and long-term services and supports (LTSS).
Phase three triggered a deeper dive into case manager caseloads and utilization patterns as well as several quality improvement activities.
Now in phase four, the goal of AltaMed's care coordination model is to ensure it can reflect a financial impact. "We'll look very closely at our per member per month cost and our inpatient metrics," Ms. Coles concluded.