In today's health care environment, consumers demand integrated health care solutions.

Key elements to this patient-centric care model include: identifying and removing barriers to care (which may not be directly health care-related), enriching communication across the healthcare team (e.g., medical home, ancillary providers), facilitating coordination of necessary care and services, leveraging community resources, ensuring appropriate level of intensity intervention at the appropriate time, educating the patient/caregiver toward health care self-efficacy, and utilizing technology in support of care delivery (e.g., EMR, patient/physician portal).

This presentation uses didactic and audience collaboration to demonstrate the value of an integrated, patient-centered care model. Discussion highlights the importance of seamless interactions across case and disease management, and presents a case study illustrating a solution provided for a patient with multiple chronic conditions and transitions of care needs. An update of payment reform for integrated care model activities will be included.