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| Debi Jefferson, Care Coordinator |
This August, I celebrated my one year anniversary with EvergreenHealth Partners. Together, we have made great progress. I am happy to say that every single day, I receive at least one positive comment related to how our EHP partnerships and process has benefited a life we have touched—be that a colleague, practice manager, physician, clinic medical assistant, patient or family member—we are benefitting lives together.
Across the nation, care managers are at the epicenter of change in health care delivery, from care transitions to coordination of services, and patient self-management engagement strategies.
Let’s talk about the role of Ambulatory Care Managers in connecting the dots for your patients from emergency room and hospitalizations, to transitional care or back to their primary care provider.
Our new Population Health Software, Wellcentive, will provide and help support our Primary Care Practices with care management, improved population prevention tracking, care coordination, improved communication, and patient safety. In September and November, the two EvergreenHealth Ambulatory Care Managers and I transitioned from our current manual care management process to Wellcentive. This is the best one year anniversary present of all!
Daily, we are an extension of your practice as we each receive alerts that identify the patients in our contracts that have been seen in any emergency room, admitted or discharged from any hospital, as well as those scheduled for elective procedures in the future—all in one platform. This functionality will give us the ability to identify hospital related activity and communicate it to the primary practice staff for appropriate patient follow-up in a timely manner and provide coordination of care. We will now know if patients were admitted at Harborview, Overlake, or another hospital or ER. We will also know what specialist they have seen from the claims data we receive from the health plans and all EHP practices sending us their office claims.
Care coordination is a service in all our contracts, yet is a vitally essential feature of our up-coming Puget Sound High Value Network, Uniform Medical Plan Plus at risk contract with the Health Care Authority that begins in January 2016.
The Health Care Authority’s intent is to have a standard process to ensure that primary care providers deliberately consider care coordination functions, explicitly assign these functions to specific provider staff —which may include myself or a EH Ambulatory Care Manager to take extra steps to coordinate the care of patients with complex needs, and communicate clearly to patients about who on their care team they can contact to help coordinate their care.
This standard promotes the Wellcentive platform we have developed to create individualized care plans for patients with complex medical and social needs, and to help coordinate and integrate these patients’ care. The Health Care Authority will identify patients with higher health risks, and we will connect them to care coordination that will effectively coordinate and manage care for higher risk sub-populations. This will help avoid exacerbations of illness and other health complications in such patients.
EHPC Ambulatory Care Coordinators Teri Coyas, RN and Jennifer Windau, RN, and I look forward to working with the practices as we roll out 2016.