The essential element for value-based payment success is the coordination of care for patients with multiple chronic diseases. Special attention will be paid to managing the chronically ill, promoting evidence-based practices and helping patients learn self-management of their disease. Patients with two or more chronic conditions will be encouraged to participate in your Care Coordination program, resulting in better outcomes, lower per capita costs and better alignment with the 20% of your patients that comprise 80% of healthcare spending in your community.
The key to Care Coordination is patient activation. Our program uses the Coleman method to motivate patients to improve their health. This is implemented through a six-week online training course through the Iowa Chronic Care Consortium, followed by in-person certification as a health coach. Those same skills are applied to integrate behavioral and mental health services into the clinic using the Psychiatric Collaborative Care model.
Generally led by a nurse in your practice or community, the Care Coordination program will use both local and virtual care teams of pharmacists, mental health professionals, advice nurses, nutritionists and community resources to support this fragile population. They will take the burden from the physicians in the clinics and the emergency room by providing the support patients need to manage their disease and avoid unnecessary hospitalizations and readmissions. Regular physician visits will be supported by clear patient goals to maximize compliance and adherence to the care plan. Referrals will be tracked and accompanied by patient data and care coordination support, ensuring a closed loop of information and the avoidance of wasteful, duplicate procedures.
The care coordinator can use the Lightbeam Health Care Management module to develop care plans, track patients’ progress and document their work for Chronic Care Management billing. Lightbeam predictive analytics can be used to create patient registries to identify patients who can benefit from Care Coordination.
Our evidence-based Nurse Advice Hotline enables you to successfully bill Medicare an average of $40 for each patient your care coordinator provides care management support for a minimum of 20 minutes per calendar month. Our care coordinator mentors, cohort calls, training, workshops and certification are all designed to develop this important skill within your practice.