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Integrated Care Coordination Update

Integrated Care Coordination Update

This year has already been a busy one for our Integrated Care Coordination program. We’ve implemented two new programs that have started very successfully: Real-time ED outreach and Follow-Up after Mental Health Discharge for Mercy Care Patients.

  • Real-Time ED Outreach: We’ve developed a program that allows PCCN’s Care Coordination team to outreach to patients within one week after being discharged from the ED. Patients identified through this near-real-time intervention are offered our traditional care coordination services, and we’ve seen an uptick in engagement and enrollment through this process.
  • Follow-Up after Mental Health Discharge for Mercy Care Patients: We’ve recently started a pilot program with Mercy Care where our team serves to facilitate and confirm follow-up appointments for patients discharged from the hospital with a mental health diagnosis. Our overall goal is to ensure that patients have a follow-up appointment scheduled with a behavioral health provider within seven days of discharge. This pilot has been an enormous success in both the efficiency of the process and the feedback we’re receiving from our community providers and our patients.

We will continue to focus on program enhancements within our Care Coordination team as we move into the latter half of 2021. Our next focus will be to further develop a definition of children with medical complexity and create a program to address the needs of those patients through our network membership.

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