Case Management —
The St. Bernards Population Health team offers an array of case management services, including:
Patient-Centered Medical Home —
Patient-Centered Medical Home (PCMH) is a health care delivery system in which patients have an ongoing relationship with a personal physician who provides comprehensive care. This physician takes responsibility for coordinating care with other providers.
The goals of PCMH are to improve the patient's experience of care, improve the health of populations and reduce or control the costs of healthcare.
The PCMH Case Manager works with the physician, clinic staff, and the patient to find the best, most efficient, economically feasible way of meeting the patient's needs with the available resources. The CM works with the patient to identify issues and barriers that may prevent them from getting the care they need and assist the patient and physician in developing a mutually agreed-upon plan to reach the best possible outcomes.
Comprehensive Primary Care Plus —
CPC+ is a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.
The goals of CPC+ are to improve the quality of care patients receive, improve the patient's health, and spend health care dollars more wisely.
The CPC+ Case Manager Case Manager works with the physician, clinic staff, and the patient to find the best, most efficient, economically feasible way of meeting the patient's needs with the available resources. The CM works with the patient to identify issues and barriers that may prevent them from getting the care they need and assist the patient and physician in developing a mutually agreed-upon plan to reach the best possible outcomes.
Collaborative Health Initiative (CHI) - CHI provides case management services for Arkansas Blue Cross & Blue Shield patients in the following clinics: Children's Clinic, Clopton Clinic, Dr. G.L. Cranfill, and Dr. Vonda Houchin. Services include follow-up phone calls after discharge from ER, inpatient stays, and outpatient surgeries to assess if follow-up appointments are made, medications filled and understood, and any other assistance needed.
Bundled Payment Care Initiative (BCPI) - BCPI is an initiative testing bundled payments through Centers for Medicare & Medicaid Services. Case Management beginning with an inpatient acute care stay for selected diagnosis - currently stroke patients. Follow-up care for these patients is 90 days after the date of discharge. It provides assistance with transitions to all levels of care after discharge – rehabilitation, long-term care, physical therapy, home health, primary care and specialty appointments, and home. The BPCI case manager also works with the post-acute care team to ensure high quality, cost-efficient care throughout the continuum of care and with the inpatient acute care team to provide evidence-based protocols.
Bundled Payment Care Initiative Advanced (BPCI Advanced) is an initiative further testing bundled payments that will begin on Oct. 1, 2018. Case Management services for selected diagnoses are yet to be decided.
High-Risk Case Management - Patients that are deemed "high-risk" by inpatient case managers for readmission are referred for case management services. Services include follow-up phone calls, medication reconciliation, coordination of appointments and services, and home visits if needed. High-Risk case managers also provide case management services as listed above for Medicare patients with the following diagnosis: COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure, AMI (Acute Myocardial Infarction), CABG (Coronary Artery Bypass Grafting, (open heart surgery), Joint Replacement and pneumonia patients.