The CCA Population Health and Care Coordination Program (PHCC) has been developed using evidence-based goals and measures that are congruent with national measurement systems.
The program’s structure is focused on multi-disciplinary teams that include (but are not limited to):
- A clearly identified and trained care coordinator;
- Established/designated primary care teams, including providers (physicians, mid-level practitioners, RNs, MAs, etc.);
- Established/designated community service providers (e.g., home health, mental health, transportation, public health, hospice, etc.).
The plan is intended to be a resource for participating organizations, care teams and care coordinators for implementing systems and processes that positively impact cost, quality and the patient experience.
Providers and primary care practices have specific roles in addition to participating in patient care teams with the care coordinators. The identification and empanelment of high-risk patients is integral to the success of any ACO. Patients benefit from empanelment by having an identified care coordinator and primary care provider. The care team assists the patient in navigating the healthcare system and adhering to the care plan. Once patients have been empaneled, the care team develops a care plan with the involvement of the patient and their family/caregiver. The providers and primary care practices also participate in quality improvement initiatives in order to meet the Three Part Aim: 1) improve the patient experience; 2) improve the health of population; and 3) reduce the per capita cost of health care (Berwick, Nolan, & Whittington, 2008).
Providers and primary care practices will use quality improvement initiatives to create robust and accurate coding processes. Improved coding processes result in accurate quality measurement. The ACO infrastructure will provide support and resources to improve coding processes and quality reporting.