Population Health Management

Information needed on this area. Recommend including differentiators or process for carrying this out.

COPE Health Solutions (CHS) best practice Transitions of Care (TOC) program follows the patient for 30 days post discharge to provide high touch support to prevent readmissions. Ensures patient understands discharge plan and has all needed home services in place, conducts medication review, post d/c assessment and applicable condition-based surveys and screenings; escalates and refers to interdisciplinary team (Social Worker, Pharmacists, Dieticians) and Community Based Organizations as needed

CHS best practice Complex Care Management program follows the patient longitudinally upon identification for 120 days.  Patients are identified for the program via referrals from other CM programs, risk stratification, or PCPs. The program provides patients with evaluations to determine the level of care needed, followed by collaboration with a care team to ensure patient needs and goals are being met. Supports health literacy and activation through education and motivational interviewing. Patient is graduated from program once all care plan goals are met and patient is empowered to self-manage

CHS best practice Disease Management program is a 90-day program providing ongoing care and support to assist individuals impacted by one or more chronic health conditions with the medical care, knowledge, skills, and resources they need to better self-manage their condition(s) on a day-to-day basis. The program provides patients with evaluations to determine the level of care needed, followed by collaboration with a care team to ensure patient needs and goals are being met. Supports health literacy and activation through education and motivational interviewing. Patient is graduated from program once all care plan goals are met and patient is empowered to self-manage

CHS best practice Care Coordination program is an episodic program targeting low risk members with acute needs for preventative and chronic gap closure, as well as those with Social Determinants of Health (SDoH) needs. The Care Coordinator provides outreach as needed to facilitate appointments for gap closure and helps reduce SDoH concerns by collaborating with the care team, Community Based Organizations (CBO), PCP, and patient’s support system. Patient is graduated from program once all gaps in care are closed and SDoH referrals are made with resources provided.

Network adequacy and optimization analytics tools  available for self service or with analyst and SME support. Also on the ground and remote network build team to build new health plan networks for any line of business.

Key Differentiators:

• Platform integrated into ARC, differentiator for both ARC and network
• Ability to provide interim/outsource network analytics team
• Ability to contract and optimize networks in all lines of business

CHS best practice Concurrent Utilization Review (UR) program leverages ADT feeds and CHS hospitalist alignment program to provide re-direction for IPA/CIN attributed members who hit the ED and can be better supported at an alternative site of care such as home based care, SNF with wound care or other capabilities, rapid specialty or PCP visit, rapid diagnostics followed by specialist visit and other options.

CHS best practice utilization management (UM) program details outlined in UM section (Other services, below).

Key Differentiators:

1. NCQA certified care management workflows contain all required documentation for quality patient care and cost management as well as streamlined processes to increase efficiency of client staff
2. Auto generation of audit packages and reports to both measure compliance with program requirements internally and export files on patient care to auditors
3. Platforms are coupled with our consulting expertise to implement and manage workflows alongside the client team

Information needed on this area. Recommend including differentiators or process for carrying this out.