Care Coordination Update

Debi Jefferson, Care Coordinator

Since September, I have been energetically assisting practice managers and providers to meet payer quality initiatives and financial incentive goals by:

• Establishing a unique process, by practice, to address high risk and care gap patients identified by our contracted payers
• Following and informing you of your hospital admits and discharges
• Referring patients to Case Management and Disease Management or other health plan services available to them
• Working one-on-one with patients to find helpful resources recommended by their provider (e.g. company health plan benefits resources, education and support groups and community support referrals).

As of January 1, 2015:   

• 109 providers (20%) have established a process with EHP to alert them of at-risk/care gap patients with our current payers.  
• 97 providers (18%) and their practice managers are slated for Q1 process set up discussions.   
• Approximately 3,500 patients (32%) have been “touched” by providing notification of their essential care gaps to their providers and supporting staff. 
• 328 providers (61%) currently do not have high risk or care gap patients attributed to them as a primary provider by payers 

I am excited about the practice and provider engagement in these processes.  In 2015, we will continue to successfully connect the dots between the payer contract and the provider to provide high quality, safe health care through our integrated network of health care providers delivering the best service and value. 

Through the shared savings contracts EHP has, it is important to remember, no one gets a black mark for anything NOT done:  everyone does!  No one gets a gold star for anything done, EVERYONE does. 

As Sara Rutherford mentions in her Quality Coordinator’s update, in our transition to 2015 our goals include establishing reasonable targets for each of our quality initiatives and tracking individual provider performance against those targets. I will be providing quarterly patient lists from First Choice, Cigna and soon Aetna and Regence ACO to practice managers and providers so that we can continue to focus on the specific, prioritized quality initiatives under each of our payer contracts.

Please feel free to call me directly to discuss any CIGNA, First Choice, Aetna and Regence ACO patient plan of care I can assist you with. I am available by phone at 425.899.2631 or by email at dajefferson@evergreenhealth.com.