The Medicaid (MA) patient population tends to see many doctors and they frequently change health plans. Some patients become ineligible only to come back on the health plan in a few months. Many of the patients go to the Emergency Department (ED) of a hospital for emergent health care, but more frequently for non-emergent health care using the ED as their “Primary Home.” Some of these issues are reasons for fragmented health care. The Primary Care provider does not even know that their patient was seen in an ED.
This poster presentation will demonstrate that coordinated care collaboration between the patient, payer, and the provider will result in reduction of HEDIS identified care gaps, improved adherence to care plans, and more appropriate utilization of health care services.
Method:
Shared planning and operational teams from Keystone Mercy Health Plan (KMHP) and Mercy Health System (MHS) improved patient-centered care by:
- Incorporating care managers from the health plan into two primary care offices to provide proactive management supporting the identification and removal of care gaps.
- Developing a community outreach team to connect members to primary care.
- Placing of a transition manager at the hospital for ED and inpatient discharge planning.
- Implementing a multi-specialty physician group.
- Fostering relationships with community-based resources.
Results:
- Nontraditional data sets identified risk populations, associated care gaps, and health care utilization patterns for MA population.
- Care Gaps were removed via primary care coordination with health plan.
- Hospital-based transition manager created connections to plan-based care management and follow-up ambulatory care.
Conclusion:
Collaboration of health plan and care delivery system offers promise for better coordinated, patient-centered care. Improve the quality of health care delivered to individuals served by both KMHP and MHS through enhanced interfaces and communication.
Recommendations:
- Develop and Implement a Model for Activation of Primary Care Visit
- Expand to additional Provider sites both offices/clinics and hospitals
- Replicate the Model to the self-pay (uninsured population)