3004 – Transitional Care Management
Centene has been operating a formalized Transitional Care Management Program to support Members’ transition of care when discharged from an institutional clinic or inpatient setting. A pilot study was launched in two health plans. Using a proprietary predictive model that was developed with Artificial Intelligence and Machine Learning, care managers would manage members with high readmission risk at the time of admission. They would document and validate the impact of on-site personnel utilizing proven Transition of Care (TOC) models to improve the discharge process and post hospital outreach coordination. The Scope of the pilot study covers acute inpatient Medical, NICU, and Mental health admissions. The validation of the TOC program will utilize data driven metrics based on preventable re-admission/outlier data, as well as the process measures which incorporate both on-site and post-discharge member interactions.
1. Describe how to reduce potentially preventable readmission’s
2. Apply utilizing artificial intelligence and machine learning for predictive analytics and proactive transition of care management
3. Summarize coordination between inpatient acute care and MCO care management process