Our member selection algorithms identify members facing a high risk of hospitalization. We identify those members who have unresolved care issues that can be corrected quickly by working directly with cooperative and motivated members. After identifying and contacting these members, we further assess candidates face-to-face, typically in conjunction with a Prospective Coding assessment. We believe that face-to-face, in-home assessments are the most effective way to evaluate issues such as medication reconciliation and adherence, fall risk, and critical caregiver support gaps.
At CCS , we refer to our ability to identify and close care gaps as impactability. Closing care gaps is not only what is best for the member, but it is also a consistent way to produce significant ROIs and improve member satisfaction. Our Impactable Care Management program includes ongoing in-home and telephonic care management activities performed by an interdisciplinary care team.
Key program elements include:
- A face-to-face, in-home comprehensive assessment
- The development of an individualized care plan
- Establishing prioritized, impactable goals such as medication adherence, reduced fall risk, regular PCP visit compliance
- The deployment of multidisciplinary care teams comprised of NPs, RNs, LPNs, and social workers
- Assisting member with community-based support and activities
- Regular communication with the member, caregiver(s), and PCP in order to improve care coordination
- 24/7 Call Center that provides back-up coverage for members
Our Impactable Care Management Program utilizes a telephone append system that will find alternate phone numbers for those members we have difficulty contacting. In addition, our Call Centers can arrange for “pop-up” visits for any member that we are not able to contact telephonically. These visits involve nurses traveling to the homes of unreachable members with the hopes of engaging them.