The Value of a Health Center-Embedded Care Management Model

Effective care management can help health centers improve clinical quality metrics, health outcomes, and for those in value-based arrangements, control patients’ costs of care. This session will detail a health center-embedded care manager model in which the managers serve as the population health champion and direct the care coordination efforts for specific high-risk patients. The session will outline how a care manager can work in collaboration with the providers and utilize a data-driven approach to identify and address high cost and high risk patients with impactable needs. It will also detail how a population health technology platform, such as the Aledade “App”, can help care managers identify appropriate patients for enrollment in care management. Next, the session will explain how care managers can leverage admission, discharge, and transfer (ADT) data to drive timely interventions after patients’ ED and hospital visits to prevent readmissions and further utilization. Finally, it will outline how care managers can identify and address specific risk factors. Using this model, health centers can engage patients in billable care management with the goals of patient activation and mitigation of modifiable risk factors that have led to high utilization patterns.