Advanced Medical Home Tier 3
CCPN Can Take You There
Tier 3 status offers new quality improvement and revenue opportunities, but also new responsibilities. CCPN can help you optimize the care you provide and qualify for improved revenue.
We use an evidence-based and scientifically-validated analytics model to that risk-stratify all empaneled patients based on “impactability” – the probability of benefiting from care management intervention.
Provide care management to high-need patients
We have a robust care management program that has served the Medicaid population for over two decades and is nationally accredited by the National Committee for Quality Assurance (NCQA). Key components:
- Local, licensed, and trained care management staff
- Patient assessment and screening
- Patient-centered care plan and web-based care management documentation platform
- Communications that keep primary care clinicians informed on patient progress
- Patient education
- Medication management
- Relationships and referral contacts established with community partners to address social determinants of health
Use a documented care plan for high need patients
We use a person-centered care plan that is informed by a comprehensive needs assessment, clinical guidelines, and patient goals.
Track Admissions, Discharges, and Transfers (ADT)
Our tools track beneficiary utilization, including ADT for empaneled patients. We receive ADT notifications three times a day from most hospitals across the state, allowing care managers to utilize real time admission data to perform transitional care for high-need patients.
Transitional Care Management
We use ADT and other information to initiate transitional care management for patients at risk for re-admission or are considered high risk post-discharge. Our standardized processes optimize the effectiveness of transitional care management, resulting in a 27% reduction in inpatient admissions and a 48% reduction in potentially preventable readmissions.