Challenges for Patients in the PCMH Model Patient case management is one of major features that PCMHs incorporate to mitigate negative effects of fragmentation care (Parker et al., 2010; Wells et al., 2008) and improve health outcomes with lower medical and administrative cost [3]. Case managers are playing an increasingly vital role in care coordination to educate patients with disease self-management skills and connect patients to community and social services within the PCMH network (Horný et al., 2017). Case managers are usually licensed health care professionals who work with PCMHs and directly contact with patients to coordinate various health care services based on each individual’s conditions (Taylor et al., 2013; Grumbach & Bodenheimer, …show more content…
Over 350 primary care practices and 1900 primary care physicians participated in the Project, which accounted as the largest demonstration project in the country. The main objectives of MiPCT were to provide better care management, self-management support, care coordination and linkages to community services ("About MiPCT", 2018). As of November 2015, 581 case managers participated in the MiPCT project to serve 1,158,650 patients across 355 PCMH practices (Rajt et al., 2015). To optimize the patient engagement, MiPCT classified case managers into three levels: moderate, complex, and hybrid roles. Patients are stratified based on their health risk levels and primary care services utilization (Beisel et al., 2012). Moderate case managers are responsible for patients with low- or mid-level health risks while complex case managers contact with high ‐complexity, high ‐cost patients. MiPCT designates one moderate and one complex case managers to every 2,500 patients within the network. In some small primary care practices with less than 2,500 patients, a hybrid case manager, who could manage both complex and moderate risk patients, is assigned to the entire team to facilitate developing individual comprehensive care plans …show more content…
As approximately 83% Medicaid beneficiaries participated in CCNC program (Paradise et al., 2013), roughly 1.5 million people received care through CCNC. Based on the recommendation of embedding more case managers into practices to decrease individual caseload from 1:4000 to 1:1250, we assume 610 more case managers are needed to participate in the PCMH model (Dubard, 2016). The total estimated spending used to hire additional case managers is $29 million, given the annual salary of $47,648 per case manager in North Carolina ("Care Manager Salaries in North Carolina | Indeed.com", 2018). 33% ED visits could be avoided because of incorporating additional case managers into the network (Crane et al., 2012), which is quoted from a cohort study conducted in a county hospital in North Carolina. The study examined health benefits for patients with complex needs by implementing a case management team of a nurse case manager and 3 health professionals. Due to the study location, intervention design that aligned with our focus on case managers and the similar size of case load for the case manager, it is reasonable to apply data from this intervention to our study. Thus, given the fact that there were over 1.2 million ED visits from Medicaid beneficiaries annually ("HCUP
Markham Stouffville Hospital (MSH) is an acute care Hospital in Markham Ontario. Every year almost 40,000 patients discharge referral transactions are conducted across 52 health care facilities in the Central Local Health Integration Network (CLHIN). I am currently working as a Hospital Case Manager (HCM) in Central Community Care Access Central (CCAC) at the Markham ...
It has taken on growing importance as health care facilities pursuing for larger investments to incorporate different systems aim at enhancing the hospital experience, medical outcomes, and clinical fiscal efficiency, as well as organize a facility for meaningful health care reforms (Barbazza, Langins, Kluge, & Tello, 2015). Health care organizations are restructuring the medical personnel structure to resolve the need for more organizational involvement, electronic medical groups, and the function of the health care physicians in a more relevant manner. They are also modernizing how they need to coordinate medical services more efficiently across the field of health care: critical, ambulatory, proficient nursing, and home care (De Vreese, Leys, Fontaine, & Dendoncker, 2016). Moreover, organizations are determining the fiscal outcomes of transferring from encounter-based structure to a performance- or capitation-based payment framework. Integrated delivery network is a physician-centered set of activities that stimulates the continuity of medical care as well as organizational and complex hospital management. Key elements comprise an incorporated technology framework that encourages the continuity of health care and permits all stakeholders to access to medicinal history of patients and other critical information (Barbee & Antle,
Furthermore, in the case of comparing the Patient Centered Medical Homes against Obamacare services the odd speak for combining some of the techniques that are used in the PCMH to build a more stable health care system. “Maria Vezina (2013) reports knowledge about the Patient Protection and Affordable Care Act (PPACA) passed in March 2010 and upheld by the Supreme Court in June 2012, is key in understanding the varied regulatory changes that have been made to our U.S. health care system. PPACA is the most significant regulatory overhaul of U.S. health care since Medicare and Medicaid in 1965. The entire health care team needs to be prepared for initiatives introduced to better manage the care for a greater population of people with improved
In efforts to address the health care needs of an individual with MCC, health care systems benefit from using the Chronic Care Model (CCM) and Transitional Care Model (TCM) when developing a patient care plan. The CCM predicts an increase in patients with self-management skills and tracking systems, by streamlining medical care through partnerships between health systems and local community assets (Mackey, Parchman, & et al., 2012). The TCM “emphasizes recognition of patient's’ health goals, coordination and continuity of care during acute episodes of illness, and development of streamlined plan of care to prevent future hospitalizations” ("Transitional Care Model," 2014, para. 1). Both models are successful with active participation of
In order to effectively implement the managed care delivery system in the country, Medicaid managed care organization should plan new strategies that minimize barriers, embrace new technologies, and create incentives for providers to deliver cost-effective, patient centered care. Some of the innovative strategies are (1) New ways of working with and paying providers to
This system provides annual statics on Medicare payment amounts for institutional providers. A nurse leader can use HCRIS to find other similar institutions with whom to compare reimbursement rates and use this information to make necessary adjustments (“Healthcare Cost Report”, 2016). Lastly, nurse leaders can also use cost-to-charge ratios, volume-based measures, per diem rates, and balanced scorecards to gain better insight of unit reimbursement (Liberty University,
His ideas of forming a diverse team (steps 2 and 4) and overcoming barriers until the vision is achieved (steps 5 and 7) are incredibly important in today’s increasingly complex health care system. Kotter (2018) focuses on the idea that the people within the organization “hold the energy” (p. 20) to make change happen. In order for change to happen and for EBP utilization to increase, Kotter makes it clear that people at all levels of the organization must be involved in the initiative. APNs must make sure they are pulling in all levels of the hierarchy into their initiatives, just as both providers and nurses were targeted in the implementation plan
Case management has become the standard method of managing health care delivery organizations today. In recent decades, case management has become widespread throughout healthcare areas, professionals, and models in the United States; and has been extended to a wide range of clients (Park & Huber, 2009). Regardless of the setting, case management ensures that care is oriented to the client, while controlling costs at the same time. Case management delivers quality care to patients in the most cost effective approach by managing human and material resources. Client advocacy is a strong underlying theme for all case management activities. Case managers share the same goals and standards of practice, but are multidisciplinary and have diverse academic educational backgrounds and work environments (Park & Huber, 2009). The need for case management and case managers continue to increase as new service needs, and populations are recognized....
Higgins, J., & Cole-Poklewski, T. (2010) Case management reform: An illustrative study of one hospital's experience. Professional Case Management, 15(2), 79-89.
In this case study, the focus is on Community Health managed by (HMO). HMO serves multiple states, and the region where membership growth in Community Health has been lackluster is the east city region. Despite economic disparities and hardship, a commitment to expand its primary care services to Fair-town, a suburban area of the east city region. This is mostly due to the opening in clinics serviced by Community Health in the area. Fair- town is a suburban area growing in population, and the target of Community Health has set a goal of 3,000 to 6,000 thousand new members over the next two years after the completion of the Fair-town Clinic.
Patient-centered care is the most effective and efficient way to provide optimal care and ensure all patient needs are met. When patients are encouraged to take on an active role in their health care, the quality and efficiency of care together with patients health outcomes can improve (Davis, 2013). Important aspects of PCC are the effective collaboration between members of the healthcare team, family-centered care, and comfort. Although PCC is seen as a general concept, in reality it contains many specific aspects that are necessary to ensure proper care of the whole
At times case managers are faced with decisions of balancing the needs of their employers, for example doing what is financially best for them, or directly doing what is best for the patient. In this case, when case managers communicate to patients that, insurance companies are denying treatments, surgical procedures doesn’t require inpatient stay, post discharge services such as homecare, or transfer to acute rehab facilities, case managers are taking the side of the organization and not the patient’s
It provides the fluidity and multidimensional complexity that is definitive of any patient’s experience that a nurse might play a part. In both experiences of transitions and the theory that attempts to understand it evolve and emerge, the gap seems to be in the implementation due to system breakdown. We are all aware that there is fragmented care, and it’s not for lack of concern by HCP and policy makers alike (Geary and Schumacher 2012). The health care system has been transforming to allow for more positive health outcomes across the continuum and attempts to identify and close the gap on the health disparities. Care coordination seems to be the missing link with not only Mr. C, but with many of the clients we have met throughout the term. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially closing this gap. A working definition formed by the Agency for Healthcare Research and Quality reveals that care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care (www.ahrq.gov). In a critical analysis of Quality Improvement Strategies, they found that care coordination for patients with diabetes showed improved outcomes, and that both disease management and case management improved glycemic control (Shojania, McDonald, Wachter, and Owens
After painstakingly evaluating each individual care model, I have observed several of the models being utilized on my unit, some on a grander than others. However, on my unit the interdisciplinary practice model is most commonly utilized. With the acuity of patients becoming more and more complex in nature, this requires more skilled and knowledgeable persons to partake in the individual care of this patient population. With increasing compound patient care needs, this model is better able to address needs and to effectively use a mix of expertise and knowledge to reach patient outcomes (Finkleman, 2012, pg 123.) The likelihood of patients being admitted to our unit with several comorbidities is about 90%. In order to ensure each problem that
According to IC & RC, Case Management is defined as, “activities intended to bring services, agencies, resources, or people together within a planned framework of action toward the achievement of established goals. It may involve liaison activities and collateral contacts” (Herdman, John W., 6th Edition). Case management is a concerted effort of various professionals in the human social services network that assess’, plans, implements, coordinates,