Clinical integration refers to the coordination of care across multiple services to improve the overall value of care provided to patients. It is a patient-centric and physician-led approach to command better outcomes and reduce costs, with proven value for patients, physicians, employers, health care systems, and payers alike.
Clinical integration is critical to the future of healthcare. Healthcare systems are moving in a clear direction away from payment-for-volume (Fee-For-Service models) to pay-for-performance. Through clinical integration guidelines and a solid foundation, Tower Health Providers (THP) is positioned to support its physicians on the forefront of this change.
About the Program
Physician participation is central to the core values of clinical integration. The innovative model for these programs provides critical support to physicians within the network help to deliver better outcomes at a reduced cost, ultimately resulting in better patient care. In addition, physicians can earn incentives for participating in clinical integration, connect with colleagues, and enjoy other benefits including:
- Recognition as one of our premier physicians across more than 50 specialties
- A focus on physician well-being and satisfaction as a critical component to patient care
- Collaborative opportunities with other physician members and care teams for coordination across the continuum
- Participation in negotiated shared savings contracts and other agreements that reward high quality performance
- Greater patient satisfaction with more effective, efficient, and affordable care that is centered around them
- Improved population health in the community
Population Health Management Services
Population Health Management is one of the key elements in a successful, clinically integrated program. Tower Health Providers has established a patient value-based platform, which improves the quality of patient care, creates better access for patients, and enhances patient satisfaction. Developed by physicians, this robust approach to population health strives to achieve the optimal health for patients, while supporting efficient, cost-effective care.
- Provide Care Management interventions to members identified at risk for poor outcomes, experiencing poor coordination of services, and would benefit from more intensive follow-up and care coordination.
- Manages effective transitions of care by facilitating hand-offs to primary care and closure of gaps in care.
- Increases continuity of care by managing and facilitating relationships with post-acute providers, physicians, and community resources.
- Promotes timely access to appropriate care and promotes effective and efficient utilization of clinical resources.
- Increases utilization of primary care services within Tower Health Providers.
- Reduces emergency room utilization and hospital readmissions via a comprehensive approach.
- Increases patients’ ability for self-management and shared decision making by setting patient specific goals with interventions to promote healthier lifestyles.
- Performs proactive outreach to members providing chronic disease and self-management education and support.
- Identifies barriers to care and connects patients to relevant community resources necessary to support health and well-being.
- Reviews open care gap reports to inform members of overdue preventive health screenings and immunizations. Empowers members to make the best decisions regarding their health.
Care Management Services
Medical management coordinates and influences utilization of healthcare resources through the ongoing evaluation of medically necessary and appropriate care in the interest of promoting quality and cost-effective care for all members.
- Precertification/notification of hospital admissions, procedures, home health care services, therapy services such as physical, occupational, and speech, and durable medical equipment
- Out-of-network care request reviews to determine if service is available within the core network.
- Discharge planning; post-acute care planning
- Continued stay/treatment review
- Post-service review
- Technology assessments
- Specialty pharmacy review (when paid under the medical benefit)
- Use of InterQual Criteria
- Use of internally developed evidence-based guidelines
- NCQA-compliant processes
- Continuity/transition of care
Collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes that improves patient value.
- Predictive modeling software utilized to predict high-cost, high-risk cases and directs and prioritizes resources resulting in the efficient allocation of services to the right people, at the right time, and right healthcare setting.
- Registered Nurse Case Managers are telephonically based, whose intense management approach has goals of achieving optimal outcomes of care and quality of life, which improves patient satisfaction.
- Members are identified through utilization review processes, claims, and member or provider referrals
- Case Management Trigger List: catastrophic illness or injury, cancers, high risk obstetrical and/or preterm infants, congenital anomalies, transplants, and other conditions where members would benefit from extra communication, guidance, and resources to achieve optimal health and improved outcomes.
Applies strategies to slow or eliminate disease progression for patients diagnosed with certain conditions and seeks to decrease acute exacerbations and hospitalizations.
- Members with three chronic conditions (Diabetes, COPD, Heart Failure, and Depression screening) identified through utilization review processes and claims analysis.
- Disease Management interventions by Registered Nurses include educational materials, referrals to support services as needed, and telephonic coaching
- Health and lifestyle coaching (weight management, exercise programs, and smoking cessation)
- Reminders of preventative screenings and other evidence-based measures
- Biometric screenings