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Community Care Coordination and Chronic Care Management

Hospital Best Practices and Recommended Strategies

The tools and resources below help leaders with community health planning and guide hospitals with developing and implementing Patient-Center Medical Home (PCMH) and other community care coordination models, as well as chronic care management services

Patient-Center Medical Home (PCMH)

  • Implement a Patient Centered Medical Home (PCMH) model to provide access to primary care and preventative care and further align with primary care physicians
  • Become certified as a PCMH to obtain opportunity for the hospital to be reimbursed at potentially higher levels for standard primary care through participation in per member per month or other payment incentives that some third-party payers have organized for PCMHs.
  • Obtain certification through National Committee for Quality Assurance (NCQA) PCMH Recognition Program. Watch the videos from NCQA on Getting On Board: Learn It – Earn It – Keep It to learn more about the certification process
  • Use the PCMH as a venue to provide chronic care management services
  • Utilize CPT codes 99490, 99496, 99495 for chronic care/transition care management (see chronic care management below for details)

Community Care Coordination Models

  • Use Rural Health Value’s care management tools to initiate the integration and coordination patient-centered care to improve clinical outcomes
  • Implement the Care Coordinator Model (CCM) to help individuals with complex health conditions to navigate the health care system. CCM assists patients and families in addressing barriers to access such as language, culture, communication, transportation and helps patients and families transition between healthcare providers and healthcare settings.
  • Use the Rural Care Coordination Toolkit to develop and implement a care coordination program.
  • Use the Community Health Workers (CHW) Toolkit to develop and implement a CHW program. CHW are non-medical health workers that help improve patient outcomes by assisting patients with learn about their disease and obtain screening and treatments.
  • Refer to Kentucky Homeplace for ways to use Community Health Workers to assist patients and families identify and find solutions to their health care needs. Kentucky Homeplace includes health educators.
  • Consider using a health navigator (HN) to assist patients through treatment and care and guide patients across healthcare settings

Chronic Care Management

Community Care Coordination Planning

  • Review IHI’s Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs white paper for suggested methods and opportunities to better coordinate care and key metrics for determining outcomes
  • Develop transition of care committee to include hospitals, physicians, emergency medical service (EMS) and other local agencies such as Home Health and Area Agency on Aging, as well as non-traditional health champions such as schools and churches
  • Develop and coordinate local providers to include home health, nursing home, hospice, emergency medical services (EMS), pharmacy, clinic, wellness center and Public Health Department
  • Host community provider quarterly meetings to initiate community health planning. These community health planning meetings benefit hospitals by establishing a venue for communication and sharing of community health resources across organizations.
  • Discuss and strategize how to meet community needs and determine the type of support needed
  • Use the Flex Monitoring Team’s State-level Quality, Financial and Community Engagement Data to support planning
  • Use the Network Care Coordination Workshop tools and trainings to initiate the development of a network care coordination service.