medical home visits: after the physician team leaves
DESCRIPTION
Medical Home Visits: After the Physician Team Leaves. Cindy Hasz, Director Grace Care Management November 10, 2004. Physician Team to Care Manager. Referral from Physician Team to Community Care Team Assessment, ID needs, Care plan, care coordination, on-going reassessment - PowerPoint PPT PresentationTRANSCRIPT
Medical Home Visits: After the Physician Team Leaves
Cindy Hasz, Director
Grace Care Management
November 10, 2004
Physician Team to Care Manager
– Referral from Physician Team to Community Care Team
– Assessment, ID needs, Care plan, care coordination, on-going reassessment
– Multidisciplinary team– Feedback system
ACUTE SYSTEM - Long Term Care - CHRONIC SYSTEM
Vertical Horizontal
Institution centered - Starting Point - Patient centered
Facility-Stationary Residence-Mobile
Crisis based Maintains Normalcy
Single-system based - Method of Delivery- Partnership based
Managed Care Care Management
RIGID - Character of System - DYNAMIC
Fixed-Slow-Inefficient Flexible-Fast-Efficient
Emergency Resolved - Functional Outcome - Health Level Sustained
SHINING A LIGHT ON TWO SYSTEMS
CURRENT MEDICAL SYSTEM
COMMUNITY CARE
MANAGEMENT
When Necessary, Patient Enters Acute System
Emergency Resolved, Patient Returns to Chronic Care
Community Care Management Allows for the Best Utilization of Both
Systems
ACUTE
CHRONIC
Community Care Management provides “Circulation”
necessary for the appropriate care for the patient
Chronic Care Management: Proactive: stabilize at home Prevents acute care use & $$ Based on Quality of Life: dignity, choice Need for recognition of value by Public
funding sources Private sources: LTC insurance,
families, private pay Improved outcomes
Client Referral Patterns
Mr. Z
92 yo, lives alone, only son out of state HTN, dementia, risk for “undue influence” APS referral, has assets, at risk for self-
neglect Cognitively unable to follow treatment plan Needed assist w/ADLs and IADLs Placement vs. home care?
Mr. Z today
In-home care carries out tx plan Controlled HTN, adequate nutrition,
safety, “Gracie”, companionship Cost is $60/day or $2000/month Mr. Z is happy and healthy at home!
Community Care Management:
Choice
Dignity
Quality of Life.Inland Comprehensive Health Care Community Care Management, Serving the Unincorporated, Rural Regions of San Diego County