Mission: To implement a physician directed and reality based patient-centric care coordination
interventions that enhance the quality of care provided to Medicare beneficiaries while at the same time combats the pronounced escalation of Medicare Program costs.
Goals: for care coordination to be consistent with the contemporary movement toward
reducing fragmentation and escalating costs within the health care system, and more specifically the published aims of the CMS Innovations Center and MSSP of "Better Health Care, Improved Outcomes,
and Reduced Costs". These Goals include:
- Reducing unnecessary use of health services (hospitalizations, emergency room visits) due to modifiable causes (e.g., change in risk behaviors, medication
compliance, reduction in risks for falls, medication management to avoid poly-pharmacy).
- Facilitating a collaborative relationship between patients, primary care providers, specialist providers, and their care manager and care coaches, through a
partnership or team based approach to care coordination, including effective integration and coordination of avoidable health, mental health, and social services personnel and resources.
- Establishing and continually reinforcing collaborative communication among primary care physicians, specialty physicians, hospitalists, care coordinators and care
transition coaches regarding where care is delivered (emergency department, urgent care facility, hospital, physician's office, patient's home or another setting), specialist assessments and
treatments, and care planning.
- Reducing unnecessary disparities in the delivery of healthcare services provided high risk patients through complex care coordination and proactive coordination of
services and assistance in navigating the health, mental, and social service systems.
- Improving the health and the quality of life of patients through intervention programs that identify, inform, and educate patients, family members, providers and
other partners in healthcare.
- Facilitating the development of effective self-management skills and enhanced empowerment among patients presenting with complex chronic morbidities.
- Improving appropriate medication adherence, self-monitoring, and appropriate lifestyle changes.
- Improving clinical outcomes through compliance with nationally recognized and accepted evidence- based clinical practice guidelines for prevention, coordination of
high-risk health behaviors, and treatment of chronic conditions.
- Implementing an integrated technology platform that supports continuity of care and enables access to medical history and critical patient data to all stakeholders,
including patients and their family members.
- Integrating clinical care and services with non-clinical community interventions (e.g., personal care services; meals and wheels).
- Measuring and tracking the outcome performance and outcome improvements yielded by the interventions through clinical and outcome evaluations based on the
administration of widely recognized reliable and valid measures and methodologies.