Chronic Care Management Program
The GHS Chronic Care Management (CCM) Program is designed to address the unique needs of the high-risk patients of GHS clients.
The Program: Facilitates, Identifies, Engages, Ensures, Ensures, Targets, Encourages, Promotes, and Systematically Monitors
- Facilitate a patient-centered and integrated team based communication and decision-making approach to care coordination and management, with direct participation of patient’s and patient’s informal caregiver (if available).
- Identify eligible patients for whom services are most likely to have the greatest impact, utilizing robust risk stratification methodologies.
- Engage in comprehensive assessment and review of individual patient needs, beliefs, behaviors, and knowledge and the development of dynamic patient centric care plans with both short and long term goals and evidence-based interventions and strategies to meet those goals in full collaboration with the patient and the patient’s caregiver.
- Ensure on-going monitoring, follow-up and revisions care plans in direct correspondence with the changing needs of individual patients.
- Ensure 24/7 patient access to a member of the Guardian care management team to address acute/urgent needs in a timely manner.
- Ensure access, continuity, care coordination, and appropriate use of services and settings in the health and behavioral health systems.
- Ensure the patient has access to and is up-to-date with age and gender specific preventive screens/assessment.
- Target transitions of care interventions to ensure better cost and quality outcomes.
- Encourage and support patient (and caregiver) engagement in self-care management and lifestyle behavior change.
- Promote and ensure patient medication adherence.
- Systematically monitor and report the impact of the Program on health service utilization, costs, quality, and patient experience.
The Program provide comprehensive care management to both commercial, Medicare and Medicaid populations and is fully compliant with the Centers for Medicare and Medicaid Services (CMS) Chronic Care Management (CCM) Program for original Medicare patients.
Key Components of the GHS Complex Care Management Program include:
- Patient Population Risk Stratification—Identification and stratification of a defined patient population into high, moderate, and low risk strata utilizing a case-mix methodology built into the Guardian IT platform that incorporates diagnosis, claims data, and pharmacy data, to capture an individual patient’s morbidity acuity and burden, with a corresponding classification of risk (high, moderate, low) based on current and projected (expected) consumption of health services.
- Patient-Centric Patient Master Chart (PMC)—Each high risk patient for whom patient participation is determined to be beneficial, an individual Patient Master Chart (PMC) is developed. The PMC is a living and breathing electronic document that organizes an individual patient’s aggregated data across a patient’s entire healthcare continuum into a singular dynamic chart that can be shared and updated by all entities interfaced with the Guardian HIE platform at the point of care.
- Comprehensive Patient-Centric Care Plan—Based on available PMC data/information, a care plan is developed by an interdisciplinary team (patient, patient’s caregiver if available, patients PCP, an assigned Guardian Care Manager or other Client identified clinical staff member, and other relevant providers associated with the care and treatment of the patient) utilizing the following set of unique tools accessible in the Guardian HIE platform:
- Guardian Care Plan Builder Application (App)--Guardian Care Plan Builder Application that facilitates the development of patient centric and evidence-based care plans for care and management of a wide variety of diseases and conditions presented by patients. The current Guardian Care Plan Builder Application contains forty disease/condition specific modules, each containing a set of evidence-based interventions that may be identified and incorporated into a patient specific care plan.
- Guardian Battery of Scales, Logs, and Form—In the interest of capturing a full picture of a patient’s needs, the Guardian platform contains an extensive battery of 178 non-proprietary public use status scales, logs, and forms that can be used in an electronic interactive recording and scoring format to identify and monitor specific aspects of the patient’s functioning. In addition, they may be used for quality improvement projects (QIPs), and/or longitudinal evaluation of changes in patient behavior or functioning resulting from targeted evidence-based behavioral and lifestyle interventions that are available in other components of the Guardian Care Plan Builder Application.
- Guardian Battery of Patient Guides and Patient Education Briefs—A battery of vetted patient guides and patient education briefs made available to care teams and patients in the Guardian Library. The patient guides are comprehensive, and have been specifically prepared to assist patients in increasing their understanding of a given chronic disease/condition and the important steps they can take to managing their chronic disease/condition.
- An Interactive Consensus Care Plan Template--A model template that allows for the integrationof a broad-base of patient data/information into a dynamic care plan (i.e., data/information from a patient’s HRA, AWV, EHR, and claims clearinghouse).
- Systematic Monitoring and Follow-Up—Methodology built into the Guardian platform that allows for monitoring and recording active and sustained patient care management follow-up where individual patients are systematically contacted telephonically and/or face-to-face, to monitor their health status, identify potential complications, and check and reinforce progress in implementing individually designed care plans.
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