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Evidence Based Care - ANSWER Helps us identify the most appropriate individualized treatment plan, improves patient outcomes, increase effectiveness and efficiency of interventions, and most current research and patient outcome measures
Empanelment - ANSWER The act of assigning individual patients to individual primary care providers (PCP) and care teams with sensitivity to patient and family preference. The basis for population health management and the key to continuity of care.
Strategic Partners Community Resources - ANSWER PCP. Outpatient clinics, Women's Health. Specialty care providers, therapists, pharmaceutical support, social workers
Accountable Care Organization (ACO) - ANSWER Improve patient outcomes through coordination of care measures and service that improve a patient's quality of life. Goal: reduce hospital readmission and improve patient compliance in community settings.
AIMS Care Coordination Model (PACO like TACO) - ANSWER Patient EngagementÂ
Assessment and Care plan DevelopmentÂ
Case ManagementÂ
Ongoing Care as Needed
Patient Engagement Phase PACO - ANSWER Interact
Ensure
Provide guidance and resources
Assessment and Care Plan Development Phase PACO - ANSWER Identify social and environmental factors that may affect medical plan adherence, health care serves utilization, and health care outcomes.
Collect information that is helpfulÂ
Develop care plan
Case Management Phase PACO - ANSWER Patient stays on track and has the supportÂ
Monitoring goal progress
Modifying the care plan as necessary
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