Asked by its C-suite to quantify contributions of its multidisciplinary care team for its highest-risk patients, AltaMed Health Services Corporation readily identified seven key performance metrics associated with the team.

Having demonstrated the team's bottom line impact on specialty costs, emergency room visits, and HEDIS® measures, among other areas, the largest independent federally qualified community health center (FQHC) was granted additional staff to expand care management for its safety net population.

Care Coordination of Highest-Risk Patients: Business Case for Managing Complex Populations chronicles AltaMed's four-phase rollout of care coordination for dual eligibles—a population with higher hospitalization and utilization and care costs twice those of any other population served by AltaMed.

In this 25-page resource, Shameka Coles, Altamed's associate vice president of medical management, describes the initial four development phases and associated challenges, as well as the composition, roles and responsibilities of the multidisciplinary care team and its impact on these multi-faceted, highest-risk patients.

Ms. Coles covers the following topics in this report:

• Development of its care management model and alignment with corporate, Triple Aim and Patient-Centered Medical Home goals;
• Identification and engagement of the target population, Medicare-Medicaid beneficiaries;
• Risk stratification of members at the health plan level into low, moderate or high-risk;
• Core functions of AltaMed's multidisciplinary coordinated care team and team member responsibilities, including the dual's own member obligations;
• Staffing and training of care team members, including the evolving role of the patient navigator;
• Recommended risk-based staffing ratios for RN case managers, care transition coaches, social workers and others handling low-, moderate- and highest-risk members;
• Development of a care management training module and workflows encompassing core health plan requirements, care management system use, integration of behavioral health, and POD management, among other topics;
• Budget preparation and 'non-traditional' ROI review prior to Phase 4 launch;
• Lessons learned, program assessment and quality improvement efforts;

Table of Contents

• A Comprehensive Care Management Model: Care Coordination for Complex Patients
  • Phases of Development and Challenges
  • Marketing Welcome and Outreach
  • Health Plan Requirements
  • Business Case for Coordinated Care Team
  • Alignment with Medical Home Model and Triple Aim
  • Business Objectives
  • Training Modules and Workflows
  • 5 Challenges of CCM Program Development
  • Staffing Ratios
  • 6 Lessons Learned in Phase
  • Phase 3 Program Assessment and Quality Improvement
• Q&A: Ask the Expert
  • Engaging Employees in Team-Based Care
  • Opt-Out Percentages
  • Patient Engagement Strategies
  • Locating Dual Eligible Beneficiaries
  • Interdisciplinary Care Team Meetings
  • Social Worker’s Role
  • Patient Stratification for Discharge Clinic
  • Health Risk Assessments
  • Aligning Hospitals with Care Team Goals
  • Health Risk Format and Risk Triggers
  • Tracking Patient Self-Management
  • Challenges of Patient-Centered Care
  • Home Visit Hallmarks
  • Defining High Utilizers and High-Risk
  • Staffing the Discharge Clinic
  • Technology’s Role in Care Management
• Glossary
• For More Information
• About the Contributor