McLaren Physician Partners

Patients discharged from Inpatient, Observation (OBS), or Skilled Nursing Facilities (SNF) are most vulnerable the first seven (7) days after discharge.  Our team provides transitional care management (TCM), including, but not limited to medication review, disease education, discharge instruction review, assistance with scheduling follow-up appointments, and identifying social determinant issues. TCM is a best practice that reduces readmissions, improves compliance with follow-up care, and supports a smooth transition “home”.

Services:

• All patients, for whom we are notified of ADT activity, are contacted
• Notifications/documentation sent to providers
• Patients are risk-stratified
• Identify those with chronic disease and refer for Chronic Care Management (CCM/CCMS)
• Social Determinant of Health Screening (SDOH) Referrals
• Assist physician/practices with billing

Population: All attributed members (MPP, MHPN), MMG unattributed

Is a critical primary care service that contributes to better patient health and care. Patients will have two or more chronic conditions expected to last at least 12 months or until the patient’s death and or that place them at significant risk of death, acute exacerbation and or decompensation, or further decline.  Patients must AGREE TO BILLING.

CCM services are extensive, including:

• Referral from provider or TCM team
• Continuous patient relationship with chosen care team member
• A comprehensive care plan for all health issues with a focus on managing chronic conditions
• Supporting patients with chronic diseases in achieving health goals
• Medical decision making
• RPM program
• 24/7 patient access to care and health information
• Review medication and any potential interactions
• Patient receiving preventive care
• Patient and caregiver engagement
• Prompt sharing and using patient health information
• Billed services with consent
• Coordinate care with home-and community-based clinical service providers

Population: Medicare FFS, qualifying Medicare Advantage Plan patients.

CCMS, also known as care coordination and disease management, is assisting patients through the healthcare delivery system, oversight and organization of care, monitoring conditions, and providing educational activities by health professionals. 

CCMS work includes:

• At-risk populations
• Motivating patients to comply with necessary treatments
• Developing goals with patient
• Care Manager assigned to patient
• Maintaining regular contact with patient targeting interventions that support goals
• Focused on self-management of disease(s)
• Discussing disease progression and end-of-life options
• Referrals accepted

Population: All patients regardless of payor can be managed in this program. Any patient declining CCM Service but still agrees to Care Coordination/Management Services.

Patients discharged from an inpatient stay to a SNF are enrolled in our care management program.  Our dedicated “SNF” team collaborates with the facility team to coordinate patient care. This collaboration includes obtaining weekly progress on family/caregiver support, prior living status, prior level of function, social determinants of health assessment, initial therapy documentation, barriers to discharge, outstanding concerns, and discharge plan.

The goals of this program are to reduce avoidable lengths of stay, ensure care is provided in the right place at the right time, oversee a smooth transition to home, and increase communication back to the Primary Care Provider to decrease gaps in care across the transition.

Services:

• Identify patients admitted to SNF
• Engage SNF regarding plan of care
• Coordinate care while in SNF
• Communicate with PCP as needed (discharge summaries, follow-up appointments, etc.)
• Transitional care at discharge

Population: ACO, Medicare Advantage

This program encompasses the services we provide in attempt to reduce avoidable ED visits.  Patients are assigned to a care manager for case review and outreach if applicable.

The work involves:

• Real-time review of ED Discharges
• Review Analytic reports of ED activity over time
• Collaborative action plan development with PCP

Services:

• Notice of frequent ED Visits sent to PCP office
• Attempt to engage patient in Care Management Program
• Collaborate with PCP to address root cause

Population: ACO, MPP attributed, referrals

This program is an extension of Care Coordination services to include after-hours availability. Designed to support patients after discharge or those who may have questions or issues that arise after normal business hours, our nursing staff is available to help until 8pm Mon-Fri and 9a-1p on Saturdays.

Audio and visual engagement of patients using the Persivia Tele-health platform.  This technology allows us two-way communication in which we can visualize the patient and environment. Any active patient can be engaged through this technology.

Services:

CCM, CCMS, TCM Services

• Referrals
• Documentation sent to provider
• Data-enabled iPads available

This is a proactive program targeting patients with chronic disease or those who are considered high-risk and recently discharged from an acute care facility. Participation is voluntarily and for those enrolled, they are engaged via phone, text or email based on personal preference.  The patient responds to a series of disease specific questions and responses are categorized through software artificial intelligence.  Patients triggering an alert, meaning they may potentially benefit from a call with a Care manager, are contacted the same day.

Population: Attributed members

This is a collaborative program between DaVita and MPP.  The program targets a reduction in avoidable utilization and reducing the number of missed treatments. ACO DaVita patients across all 10 McLaren regions are populated monthly and followed with a risk score.  DaVita sends weekly updates to the Care Management team identifying patients with rising risk or identified needs. The Care Coordinators assist with these asks and can also request assistance from DaVita on patient needs.  Patients discharged from an inpatient setting are immediately sent to RN care coordinators for follow up.  There are monthly meetings to discuss case reviews and quarterly meetings to monitor the program and review statistics.

Population: ACO

Care Coordination accepts referrals from practices, providers, hospitals, and patient self-referrals into any of our programs. Patients are also given our 1-844 number at discharge for questions or issues arising after discharge. In most cases referrals are processed in one business day.

Members of the McLaren Physician Partners Leadership Team lead the Committee with the goal of sharing best practices related to discharges, disposition location, follow-up care, and reducing readmissions. The team participates in case reviews, reviews readmission data for trends, and develops tactics to reduce avoidable utilization. Representation from all McLaren Hospitals is expected.

A proactive program, working to reduce inappropriate SNF placements by reviewing inpatient medical records at admission and throughout the acute care length of stay and collaborating with inpatient care management and therapy teams.  Patients requiring SNF placement will continue to be referred and transferred to SNF, however patients that would benefit, and are more appropriate, for a Discharge to Home with alternative services, such as Home Health or Palliative Care or Hospice, would be recommended to do so.  The goal is to collaborate and identify the most appropriate discharge plan for each patient that considers the patient’s safety, family support, living situation, current functional status, overall health, and cost of care. 

Population Definitions:

MHPN/ACO: Medicare FFS attributed members

MPP Attributed: Patients in a Value-based or at-risk contract such as Medicare Advantage Plans, McLaren Medicaid

If you have questions regarding any of our programs, please contact:

Sandra.kaltz@mclaren.org

Department Manager

(586) 741-4229

Andrea.phillips1@mclaren.org

Department Director

248 484-4947