Care Management
The NCHA Care Management (CM) program is an integral component of the Accountable Care Collaborative (ACC)/(Regional Accountable Entity (RAE).
Who We Are
NCHA Care management believes that a person’s mind, body, and spirit continuously interact with one another and their world around them. Our philosophy embraces that care should be coordinated, members must have an active decision-making role in their healthcare, and primary care providers should receive the support and resources they need to treat members in a holistic manner. NCHA believes in unconditional care and collaboratively works with the member to overcome barriers, identify gaps in care, and obtain needed resources. A principle objective of the care management team is to promote member self-management of medical, emotional, and personal issues. This may be accomplished by improving self-confidence and motivation, not only through education about specific medical or behavioral conditions but teaching skills in goal setting and planning. Our hope for all members is that they accept personal responsibility for self-management and improve communication with physicians, pharmacists, and other caregivers to build effective relationships, reach informed decision making regarding healthy lifestyle choice on medical treatment and other aspects of his/her health care.
The NCHA Care Management Team is dedicated to providing compassionate, non-judgmental, and respectful care coordination for Members following the principle that CM should happen at the right place, right time and include the right care management activity. We strive to make sure our members have access to quality coordinated healthcare and provide them with the resources to make the most of their Health First Colorado plan and health benefits. We believe in “Unconditional Healthcare” by expanding access, improving quality, eliminating disparities, controlling costs, and enhancing care experiences.
What We Do
We strive to Improve health outcomes of patients/members by:
- Providing continual linkage, support, communication between the member, the PCMP, and other involved entities to ensure continuity of care by reducing fragmentation, avoiding gaps in care, avoiding duplication, improving quality of the member’s experience in obtaining shared goals.
- Reinforcing integrated, holistic, and dynamic care for physical and mental health. CM embrace the philosophy of Cura Personalis, “Respect for all that makes up each individual”
- Supporting cost effective quality care and services
- Promoting the Medical Home concept and PCMP engagement
- Encouraging and educating all members on good preventative care
- Collaborating with community agencies and various providers to avoid duplication and enhancing bidirectional communication by using Collaborative agreement and process.
- Facilitating appropriateness of care (right care, at the right time, and right setting)
- Identifying opportunities and establishing care plans that will improve access to medical care, behavioral health engagement, community resources, and social supports for members with complex, physical, behavioral, and cultural health care needs
- Advocating for the member and supporting him/her in reaching informed decisions, an optimal state of wellness, and independent living in the community
- Promoting improvements in overall physical and mental health status of members
Health Care Transformation
We actively facilitate and embrace the transformation of the patient/medical centered health care system to people (person) – centered health by:
- Fostering patient/member empowerment to improve self- management of medical, emotional and personal needs.
- Providing care coordination necessary for patients/ members to achieve their desired health outcomes.
- CM use screening, assessment, and stratification tools to set person centered goals and to establish needed CM involvement on a continuum from brief, episodic, to intensive care management activities.
- Facilitating communication and coordination across all providers, care givers, and stakeholders.
- Providing medication reconciliation between members, involved care givers, homecare, and providers.
- Providing support and education to members and providers.
- Ensuring appropriate, timely referrals are made and information is shared among providers.
- Coordinating, monitoring, and following-up to ensure goals are being addressed, services are being delivered, and the member is working towards the desired health outcome.
- Promoting satisfaction with case management services within the member and provider community by making diligent attempts to address problems, resolve grievances, and eliminate “gaps” and barriers in care.
- Providing access to clear, concise, and intelligible health and wellness materials to delay and/or prevent disease progression and increase health literacy
- Facilitating communication and coordination across providers, care givers, and stakeholders.
- Providing medical management support to the PCMP, specific to the capabilities of the PCMP and by supporting the member in health care decision-making.
- Creating efficiencies by decreasing duplication and overlap of services resulting in improved health outcomes and cost containment.
- Being health care change agents to decrease siloes of care, working to address social determinants of health, changing damaging patient labels, and bringing down the barriers of care one barrier at a time.
Bright Spots
Our care management team has been sharing encouraging stories during these challenging times. Click here to read these and learn more about the impact our work is having on our members.
Who We Serve
We provide CM services to Health First Colorado Medicaid members utilizing over 30 different primary care medical homes in these counties:
- Southern Larimer
- Weld
- Logan
- Sedgwick
- Yuma
- Kit Carson
- Lincoln
- Washington
- Morgan
- Cheyenne
- Phillips
We serve members of all ages from various walks of life.
Longitudinal Model
We embrace a longitudinal model of care management that can transform outreach, engagement, continuity of care, and implementation of a person centered care plan by:
- Extending CM in a variety of settings and across multiple sites and agencies, “meeting the member where they are at” including homes, shelters, facilities, hospitals, clinics, resources, alternative locations (street, parks), and NCHA Walk-in office.
- Use of technology per member’s choice, phone, email, text, MyDigital, Easy care, etc.