evolving risk Established 100% of High Utilizers Patients Hospital, and High utilizers longitudinal care have a care plan: PCMH plan ED doc will start a care plan send to PCP. The PCP completes the care plan. Hospital will start the pt. on a care plan prior to discharge Shared Care 100% of patients with data CRISP High utilizers Profile shared through HIE in Care Profile; utilized by providers Portion of target % of High Utilizers Patients PCMH High utilizers pop. with contact with contact with an assigned from assigned care manger: care manager 70% of targeted patient population have contact with a CM or TOC Table 3. Programmatic Metrics and Goals Program # Project How will resources be used? goals/outcomes -Reduce ED and -Top 100 utilizers of care at GBMC will be hospital utilization at reviewed monthly and revisited by case GBMC 1 Top Utilizers case manager manager -Change location of -Patients will be followed up by case care from ED to manager and have individualized care plans primary care practices Top Utilizers Service Coordinator -Reduce ED and -High utilizers will be paired with - enrollment in community hospital utilization 2 coordinator to sign up for community programs in coordination with -Increase enrollment resources SW case manager in insurance plans -Having a pharmacist partner with students will provide a full-time resource to review -Reduce ED and Clinical pharmacist - partnership high utilizer patients' medications upon hospital utilization 3 with student pharmacists - discharge and in the patient’s home explain -Reduce medication reconciliation the purpose of each medication readmissions -Pharmacist will join care management team
evolving risk Established longitudinal care plan 100% of High Utilizers Patients have a care plan: ED doc will start a care plan send to PCP. The PCP completes the care plan. Hospital will start the pt. on a care plan prior to discharge Hospital, and PCMH High utilizers Shared Care Profile 100% of patients with data shared through HIE in Care Profile; utilized by providers CRISP High utilizers Portion of target pop. with contact from assigned care manager % of High Utilizers Patients with contact with an assigned care manger: 70% of targeted patient population have contact with a CM or TOC PCMH High utilizers Table 3. Programmatic Metrics and Goals # Project How will resources be used? Program goals/outcomes 1 Top Utilizers case manager -Top 100 utilizers of care at GBMC will be reviewed monthly and revisited by case manager -Patients will be followed up by case manager and have individualized care plans -Reduce ED and hospital utilization at GBMC -Change location of care from ED to primary care practices 2 Top Utilizers Service Coordinator - enrollment in community programs in coordination with SW case manager -High utilizers will be paired with coordinator to sign up for community resources -Reduce ED and hospital utilization -Increase enrollment in insurance plans 3 Clinical pharmacist - partnership with student pharmacists - medication reconciliation -Having a pharmacist partner with students will provide a full-time resource to review high utilizer patients' medications upon discharge and in the patient’s home explain the purpose of each medication -Pharmacist will join care management team -Reduce ED and hospital utilization -Reduce readmissions
1.%20GBMC%20Proposal.docx