PP302 – Carelink CareNow – An Innovative Care Management Approach to Achieving Optimal Health
Christiana Care Carelink CareNow is an innovative, interdisciplinary care management team supporting primary care and specialty physicians and their patients. Leveraging real-time predictive analytics to manage transitions throughout the continuum, Carelink CareNow provides information technology-enabled care coordination. The population health electronic health record prompts the team about members needing intervention or guidance so meaningful engagement can be executed by the right person at the right time. The Transitions of Care Team outreaches to members post utilization to ensure timely follow-up with appropriate providers review discharge instructions and medications, assess for additional services, and support self-management. Members are enrolled in disease specific programs as needed. Measures of success for this program include a29% decrease in Emergency Department use and a 27% decrease in readmissions 30 days post discharge for over 7700 patients served.by the team. The Community-based team (team)focuses on engagement with members of the community in their primary home setting to ensure timely access to health and social needs. The Team engages with members to identify and address social determinants of health, and access to care. Since inception, measures of success demonstrate: 35% decrease in Emergency Department use 30 days post program, 22% decrease in hospital days 30 days post program, $1.03 million in estimated savings. Conclusion: Through innovative care management, the Carelink CareNow team serves our neighbors as respectful, expert, caring, partners in their health by creating innovative, effective, affordable systems of care that our neighbors value. Utilizing our current measures of success, Carelink CareNow strives to be even better tomorrow.
1. Describe how to create a resource stewardship approach to meet your population needs through the building of a collaborative care team model that addresses both routine and high risk patient needs.
2. Explain how to analyze needs and build collaborative care teams that work to improve outcomes across the continuum of care.
3. Identify best practice implementation of collaborative strategies that improve clinical, social, and behavioral health outcomes.