2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Long-Term Carephysical health, behavioral health, and longtermcare providers (a list of policies andprocedures is available athttps://www.phs.org/providers/cliniciansresources/)Data exchange and access to clinicalinformation across systems of care throughtechnology solutions that include• Presbyterian’s web-based caremanagement platform, where providerscan access data regarding claims,authorizations, member risk stratification,and care coordination• Community Connect, an external providerEpic tool for smaller providers withouttheir own electronic health records (EHRs)• Data interfaces with providers’ existingEHRs and our care management platform• Data dashboards with actionable memberinformation that allows providers tomonitor members’ outcomes and theirperformance against specific standardsCare CoordinationPresbyterian’s member-centric care model isdesigned to integrate physical health, behavioralhealth, and long-term care services into a seamlesscare system that provides members withappropriate services at the right time within theleast restrictive and most cost-effective setting. Ourlong-term care providers play a key role in thisprocess by engaging members, participating in careplanning efforts, and ensuring comprehensive,coordinated, and culturally appropriate care foreach unique member. The care model promotescollaboration and supports providers in advancingwellness and promoting independence, resiliency,healthy living, health literacy, and personalresponsibility. A comprehensive understanding ofthis model by our providers is critical. The followingsubsections describe our care model’s corecomponents.Risk Stratification and Comprehensive NeedsAssessmentAll members receive a Health Risk Assessment(HRA), are assigned to a level of care coordination,and are partnered with a dedicated carecoordinator. Members are matched with anappropriate care coordinator based on their clinicalneeds, geography, language, cultural preferences,and history of established relationships with aprovider or community-based service agency. AllLevel 2 and Level 3 members receive an in-personCNA to identify and prioritize their clinical,behavioral, functional, and social support needs.Interdisciplinary Care Plan TeamBased on the results of the CNA, an individualizedcare plan is developed for each member and anappropriate ICPT is established. The ICPT includesthe member and all providers, including PCPs,specialists, and support providers, along with anyadditional resources needed to fulfill the care plan’sgoals, such as a behavioral health provider and/orpharmacist. The care plan is reviewed, approved,and signed by the member. The ICPT is structuredto address the member’s specific needs and is acentral component of the care model. Members areencouraged to actively participate in the care10-92014 Practitioner and Provider Manual - Ver. 3