Traditionally, both medical care and social services are provided in a landscape dominated by fragmented care and service silos. Programs or medical practices are designed to focus on their individual specialties and providers are frequently unaware of resources that are available outside of their field of expertise, much less which resources are being utilized by their individual clients. This disjointed approach often subjects individuals with complex needs to a myriad of non-coordinated care plans, a strategy which leads to frustration and poor outcomes.
The overarching goal of Medicaid providers is to improve patient outcomes and reduce costs. According to the Agency for Healthcare Research and Quality, “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 healthcare 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.” Enter 1115 Medicaid Whole Person Care Waivers.
Whole Person Care Waivers
The whole person care pilots include primary care, behavioral health, and community-based social service providers who address the full social determinants of health for vulnerable individuals. For example, providers could work together to get a homeless individual housing, care for diabetes, counseling for behavioral illness, and help to obtain employment. Conscious, whole person care coordination not only improves the individual’s experience, but also leads to better long-term health outcomes as demonstrated by fewer unnecessary trips to the hospital, fewer repeated tests, fewer conflicting prescriptions, and clearer advice about the best course of treatment.
Comprehensive Care Plans
A Comprehensive Care Plan is a holistic, dynamic, and integrated plan that can be shared between multiple providers to coordinate care in real time and evaluate individual progress. A Comprehensive Health Record incorporates an individual’s entire medical history, including health, behavioral health, and health-related social needs. As Medicaid providers look to care coordination strategies for their patients, Comprehensive Care Plans provide a deeper, more meaningful view of the “whole person” and communication and coordination is vastly improved as patients transition across settings.
Chilmark Research highlights eight “core” elements needed in a successful Comprehensive Care Plan:
- Patient demographics
- Members of the care team
- Any care management programs the patient is in
- Active problem list
- Active medication list
- Goals, including those for self-management
- All health interventions and their current status
- Risk factors for the patient
These elements support efforts to improve quality and convenience of care, increase patient participation, enhance the accuracy of diagnosis and health outcomes, and improve care coordination.
When combined with the resources to provide whole person care, Comprehensive Care Plans equip providers with the tools they need break down care silos and help individuals receive the resources they need to improve their health and their lives.
BLOG RESOURCES
https://www.ahrq.gov/professionals/prevention-chronic-care/index.html
http://medcitynews.com/2015/12/chilmark-longitudinal-care-plans-key-to-health-its-potential/
