Primary Care practices can participate in two collaborative care coordination programs as members of Mary Washington Health Alliance. Both programs provide staff and financial support to offset the cost of performing care coordination activities such as wellness visits, early follow-up appointments after a hospital discharge and addressing “gaps” in evidence based quality measures. Table 1 provides a comparison of our two care coordination programs.
The “embedded” care coordination program began in 2016 and currently has 6 primary care practices participating (33% of those eligible). This program is directed towards our Medicare population and provides incentives for completing four activities: performing Annual Wellness Visits (AWV’s), contacting high risk patients, seeing patients early after discharge and closing quality measure gaps. This program does require a degree of documentation specific to each patient encounter. The Alliance staff work with a key contact at each practice to collaborate and ensure success of this program.
The Commercial Collaborative Care Coordination program was initiated in April 2017 and currently has 21 primary care practices participating (55% of those eligible). This program is geared towards our commercial contracts (Aetna, Cigna, Innovation Health) and allows more flexibility in the activities a primary care practice can choose to perform each quarter. The Alliance provides data related to high risk patients, patients with frequent ED visits or hospital readmissions, and “gaps” in evidence based quality measures. Pediatric practices are eligible to participate in this program. The Alliance staff provides support for analyzing data and creating quality improvement processes.
The Alliance staff includes four registered nurses with advanced degrees who have experience in working with patients with multiple co-morbidities and complex social issues. These nurses target high risk and rising risk patients who may benefit from consultation in areas such as medication assistance, transportation, disease specific education and continuity of care. These nurses work closely with the primary care practices to ensure smooth transitions of care.
If you would like to learn more about the Alliance Care Coordination programs, please contact Joan Snyder, Population Health Manager, (540) 741-2119 or joan.snyder@mwhc.com.