Clinical integration refers to the coordination of care across multiple services to improve the overall value of care provided to patients. It is an approach to command better outcomes and reduce costs, with proven value for patients, physicians, employers, healthcare systems, and payers alike.
On January, 24, 2014, THP and Tower Health leadership present the Clinical Integration Program to the Federal Trade Commission in Washington, D.C. The FTC determined the program met all requirements for proceeding as a clinically integrated network.
Clinical integration is critical to the future of healthcare. Healthcare systems are moving in a clear direction away from payment-for-volume (Fee-For-Service models) to payment-for-value. Through clinical integration guidelines and a solid foundation, Tower Health Providers (THP) is positioned to support its physicians on the forefront of this change.
About the program
Physician participation is central to the core values of clinical integration. The innovative model for these programs provides critical support to physicians within the network help to deliver better outcomes at a reduced cost, ultimately resulting in better patient care. In addition, physicians can earn incentives for participating in clinical integration, connect with colleagues, and enjoy other benefits, including:
- Recognition as one of our premier physicians across more than 50 specialties
- A focus on physician well-being and satisfaction as a critical component to patient care
- Collaborative opportunities with other physician members and care teams for coordination across the continuum
- Participation in negotiated shared savings contracts and other agreements that reward high-quality performance
- Greater patient satisfaction with more effective, efficient, and affordable care that is centered around them
- Improved population health in the community
Care Coordination with PCPs
Clinical integration offers patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.
- Registered Nurse Care Navigators monitor health-related conditions, provide members education for the purpose of improved self-management, support family caregivers, and help connect members with community resources.
- Care Navigators are telephonically based as well as embedded within the Primary Care Physician offices to:
- Assists members to set goals and develops care plans with interventions for unhealthy lifestyle/habits
- Assists members with care transitions from acute hospitalization to home or specialized facilities to reduce risk of readmissions (minimum of four calls in 30 days)
- Coordinates post discharge physician visits
- Medication reconciliation with pharmacist
- Reminders of preventative screenings, depression screenings, and other evidence-based measures
Care Management Services
Medical management coordinates and influences utilization of healthcare resources through the ongoing evaluation of medically necessary and appropriate care in the interest of promoting quality and cost-effective care for all members.
- Precertification/notification of hospital admissions, procedures, home health care services, therapy services such as physical, occupational, and speech, and durable medical equipment
- Out-of-network care request reviews to determine if service is available within the core network
- Discharge planning, post-acute care planning
- Continued stay/treatment review
- Post-service review
- Technology assessments
- Specialty pharmacy review (when paid under the medical benefit)
- Use of InterQual Criteria
- Use of internally developed evidence-based guidelines
- NCQA-compliant processes
- Continuity/transition of care
- Collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes that improve patient value
- Predictive modeling software utilized to predict high-cost, high-risk cases and direct and prioritize resources resulting in the efficient allocation of services to the right people, at the right time, and right healthcare setting
- Registered Nurse Case Managers are telephonically based, whose intense management approach has goals of achieving optimal outcomes of care and quality of life, which improves patient satisfaction
- Members are identified through utilization of review processes, claims, and member or provider referrals
- Case Management Trigger List: catastrophic illness or injury, cancers, high-risk obstetrical and/or preterm infants, congenital anomalies, transplants, and other conditions where members would benefit from extra communication, guidance, and resources to achieve optimal health and improved outcomes
- Applies strategies to slow or eliminate disease progression for patients diagnosed with certain conditions and seeks to decrease acute exacerbations and hospitalizations
- Members with three chronic conditions (Diabetes, COPD, Heart Failure, and Depression screening) identified through utilization review processes and claims analysis
- Disease Management interventions by Registered Nurses include educational materials, referrals to support services as needed, and telephonic coaching
- Health and lifestyle coaching (weight management, exercise programs, and smoking cessation)
- Reminders of preventative screenings and other evidence-based measures
- Biometric screenings