- How should a health care organization develop and embed a care management program in primary care to improve care and reduce costs for high-need older adults?
- What variables factor into making the program financially sustainable?
- What tools and resources can support the day-to-day work of a care coordinator managing high-need older adults?
This resource describes how to develop and implement a model called the Intensive Outpatient Care Program, which uses a multidisciplinary team-based approach to address medical, behavioral, and social needs of patients.
- The staff position of care coordinator is crucial to success. Each care coordinator works one-on-one with a dedicated caseload of older adults.
- Care coordinators can be from a variety of clinical and even non-clinical backgrounds, and they require initial and ongoing training and support.
- The elements of a successful care model include a shared action plan; regular communication between care coordinators and participants; around-the-clock access for participants to their care team; and warm handoffs from the care coordinator to non-medical resources such as home health services, transportation services, and behavioral health care.
- A person-centered care team focuses on the participant’s own goals for health and well-being, producing a strong partnership and shared goals between the participant and care team.