Areas of focus The target population of the I-PiCC pilot was high-risk, high-cost elderly individuals living in the community with multiple co-morbid conditions who would benefit from greater PCP integration…
Fully integrated managed care models The Arizona Long Term Care System, Minnesota Senior Health Options, the Wisconsin Partnership Program, and the Program for All-Inclusive Care for the Elderly (PACE) are…
Circle 1 represents the absence of health problem(s), treatment emphasis is condition prevention. Circle 2 represents the presence of a health condition(s), treatment emphasis is condition management. Circle 3 represents…
html xmlns=”http://www.w3.org/1999/xhtml” xmlns:ops=”http://www.idpf.org/2007/ops” xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance”> Chapter 17 Introduction to Medicaid care management Allison Hamblin and Stephen A. Somers Introduction Many of those served by Medicaid are relatively healthy, with only routine…
html xmlns=”http://www.w3.org/1999/xhtml” xmlns:ops=”http://www.idpf.org/2007/ops” xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance”> Chapter 15 Summa Health System and Area Agency on Aging Geriatric Evaluation Project Kyle R. Allen, Joseph L. Ruby, Susan Hazelett, Carolyn Holder, Sandee Ferguson, and…
Practice-based initiatives As discussed earlier, the medical or health home has received attention largely because of its potential to improve the care for patients with chronic conditions. A number of…
html xmlns=”http://www.w3.org/1999/xhtml” xmlns:ops=”http://www.idpf.org/2007/ops” xmlns:xsi=”http://www.w3.org/2001/XMLSchema-instance”> Chapter 9 Education of the interdisciplinary team Emma Barker, Patricia J. Volland, and Mary E. Wright Introduction As the nation’s population continues to age at a…
The approach toward care coordination in an intervention can be captured by looking at a set of key components or features, which we will call “intervention domains.” These domains have…
Discharged to Community Polypharmacy of 7+ medications Must meet one additional criterion: Lives alone Is without a source of emotional support Is without a support system for care Discharged with…
Phase I: patient interviews In 2005-06, we conducted interviews with 50 FFS Medicaid patients who were identified with predictive methodology used by our current Hospital to Home program. This process…
