Aligning dynamic patient relationships with tailored, evidenced-based assessments over a patient-directed care network inclusive of clinical and social care teams transform care coordination programs. When healthcare practices embrace measurements of preventative care metrics and social determinants of health, they address health equity concerns through reimbursable care coordination programs like Medicare’s Chronic Care Management (CCM). The actionable data gathered point to necessary improvements involving social determinants of health (SDoH) as well as clinical health outcomes across risk stratified patient cohorts. Unexpected, positive outcomes arise when optimizing CCM programs from enhanced patient-centric engagements to reduced provider administrative burden.   

Colorado and Wyoming-based LIV Health exemplifies such a practice through their dedication to total patient engagement with a foundation of data-driven care coordination. LIV’s wrap-around managed care programs are enhanced with direct patient-initiated clinical and SDoH feedback, manifesting insight to the staff to impact healthcare outcomes and health equity decision making, coupled with the ability to demonstrate these outcomes.  A freestanding model, Liv Health providers report their clinical findings to the PCPs as well as inform them of the other SDoH that may be impacting the patient’s overall health.

“[Before CMS Care Coordination programs] I could see the train running down the track toward acute healthcare events like falls in our elderly population.  Even as a provider my hands were tied. Since implementing our CCM program, we can be proactive and receive remuneration for education and other care coordination services.  Through CCM, we can help prevent falls, strokes, and other acute healthcare events.”  –Dr. Stefka, MD.

Following LIV Health’s Example: Practical Implementation

1. Survey or Analyze Current Populations from both qualitative and quantitative perspectives:  What chronic conditions are prevalent? Does your aging population have similar needs when it comes to housing, food insecurity, etc.? How are patients experiencing their quality of care within the care coordination program?
2. Determine what metrics to track: A1c, BP, SDoH, Z codes, satisfaction with their care coordination program, self-reflection on improvement with personal goals, etc.
3. Use the CrossTx assessments tool to track qualitative and quantitative results
4. Visualize the results with auto-populated graphs
5. Enhance patients’ results with personalized changes to their care

Objective and Subjective Improvements in Care

Assessments and surveys help LIV Health drive the overall objective and subjective improvements benefiting patients.  From visualizing A1c trends to monitoring mental health patients’ response to medication, care navigators adjust the comprehensive care plan for care coordination programs like CCM.  Using patient-centric surveys, care coordinators ensure that patients align to  care pathways supported by the  social supports necessary to thrive. To address health equity or social determinants of health (SDoH) concerns, many aging patients need additional support from their local senior citizen center, area agency on aging, meals on wheels, rides to appointments, mental health resources and other community-based supports.  Care Coordinators are the point of contact intimately connected to the daily lives of their patients; they are best suited to build the relationships necessary to appropriately ask personal survey questions and receive accurate answers.

Natasha Urbank, LIV Health RN emphasizes the value of the CrossTx Care Coordination program from the nurse’s perspective, noting the actionable data gathered from tailored assessments and surveys. “We were able to build many assessments into the program and through them discover important elements in the longitudinal record of care for the patients.” She continued “We don’t have to try to do the math on the last four PHQ9s to determine if a patient’s mental health is declining, it is easily visible in a graph format. Without visualizing the month over month change in a patient’s health, we would not be able to adequately explain how valuable and transformational our care coordination program really is.” 

Reducing Provider Administration Burden—Pre-Visit Planning

Much of the appointments for CCM eligible patients are spent with the provider researching the patient’s record. However, when care coordinators organize the CCM patients’ chart before the appointment with the most relevant concerns, providers can use this knowledge to reduce the administrative burden during visits.

Natasha Urbank, RN adds with “Pre-visit planning helps providers focus on the top items of concern during visits. Providers can spend more time consulting with their patients and listening to them, rather than researching their file. That work has already been done.” She continues “care coordinators are the liaison between providers and patients that ensure preventive and routine care is complete and timely within the record.   This necessary effort extinguishes barriers between visits.”

CCM care navigators are perfectly situated to use the activity called“pre-visit planning” as a way to give provider insights in a comprehensive way before the next face-to-face appointment.   The “pre-visit planning” activity is where care coordinators organize the providers’ notes, preventative care treatment plan, specialist treatment plans, health equity, SDoH concerns, and medicine reconciliation, so that providers do not have to search their EHR extensively before appointments. 

Conclusion: Progressing Healthcare

Innovative and progressive healthcare organizations like LIV Health engage their patients and improve outcomes with care coordination programs such as Chronic Care Management (CCM.) The recipe for a transformative CCM program with thriving patients has the ingredients of 1) caring nurses like Natasha Urbank, 2) assessments marking patient progress and subjective criteria, and 3) access to care to address social determinants of health.

“With actionable patient data, we are changing the healthcare model to include both ‘health’ and ‘care.’ Utilizing care coordination as a foundation, we can transform the healthcare system into something more people feel comfortable aging into.”  Concluded Dr. Kristina Stefka.

About LIV Health and Dr. Stefka

LIV Health is a team of caring, experienced mental health and medical professionals, working one-on-one with our patients to navigate paperwork, create care plans, provide counseling that brings all elements of case management, counseling, medical and supportive services directly to our patients’ homes or their nursing home/assisted care facility. The providers and staff of LIV Health know that Every situation is unique, and no solution is one-size-fits-all. Here’s how to get started with LIV Health, whether it’s mental health counseling, medical services, case management, or community caregiving.

Dr. Kristina Stefka is the Chief Medical Officer at LIV Health.  After graduating and practicing as a hospitalist she decided to focus on caring for the elderly and chronically ill.  In 2003, Dr. Stefka completed a fellowship in Geriatric Medicine at the University of Colorado.  Since that time, she helped start the first Palliative Care Program in Wyoming.  Dr. Stefka is interested in helping to innovate systems of medical care to allow patients and families to more easily participate in their care and make informed choices based on each individual’s goals and values. She believes that great medical care begins with listening to the patient!

About CrossTx

CrossTx has developed a market-leading Chronic Care Management, closed-loop referral management, and care coordination platform to support the transition to value-based health care and the Centers for Medicare and Medicaid (CMS) overarching plans for full embrace of alternative payment models by 2030. A 100% cloud-based, secure and compliant referral network combines with care coordination and compliance features, ensuring eligible clinics successfully embrace the CMS Chronic Care Management program, which includes not only CCM but also Behavioral Health Integration (BHI), Principal Care Management (PCM), Remote Physiological Monitoring (RPM) and other programs. CrossTx combines ongoing continuous innovation, deep CMS compliance expertise and care coordination best practices to help customers better care for patients, improve costs and drive quality outcomes for providers. Learn more at www.crosstx.com.

Chandra Donnell
VP Client Success