Centralized Care Management

The Centrazlied Care Management Team is a small multidisciplinary team working with six community health centers and a Medicaid Managed Care Organization. The goal of this collaboration is to achieve improved outcomes for health center patients enrolled with the MCO .

HIGH RISK COHORT

• Top 2% spend MCO members
• HFP works with each health center to determine which of these members are appropriate for care management
• HFP team completes outreach to schedule patients with their health center PCP 

CARE GAPS

• HbA1c Poor Control (>9.0%), Annual Dental Visits, Breast Cancer Screening, Well Child visits (age 0-21)
• Review care gap data from United with the health center
• Perform chart reviews using i2i Tracks
• Explore outreach options to close care gaps

Transition of Care

• Daily review of HSX for Emergency Department and Inpatient events
• Outreach performed to priority patients (efforts made to avoid duplication)
• HFP team reviews discharge instructions with patients and encourages 7-day follow up