PP310 – Care Transition Program
In 2017, Anthem Care Management implemented an enhancement to the existing Case Management program that focused on the inpatient population with a high propensity for readmission.
Anthem Care Management developed a proprietary member identification model to target the highest risk members most likely to experience a hospital readmission.
In addition to the member identification strategy, the care transition program (enhanced the Case Manager’s ability to identify and intervene at critical junctures capitalizing on teachable moments. When a member was discharged from an inpatient facility to home, the care management follow up process aligned with the four key interventions:
Red Flag Recognition
Follow Up Care
Member Centered Health Record (Personal Health Record)
The enhanced management process resulted in a statistically significant reduction in acute inpatient use and avoidable emergency room usage.
1. Discuss how the Care Transition Program can be leveraged to support case management to improve targeted health care delivery across the care continuum
2. Discuss how frequent telephonic outreach combined with strategic activities decreases the likelihood that the member will experience an avoidable hospitalization and/or emergency room visit
3. Describe how an effective predictive analytic model enhances the ability to target vulnerable and impactable populations