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PCCN Year In Review

PCCN Year in Review

This year was a year of many accomplishments for PCCN. As we reflect on what we’ve done and what we’ve accomplished together, we wanted to share a few highlights that our clinical programs have achieved during 2021 and what we’re looking forward to in 2022:

Integrated Care Coordination (ICC):

In 2021 ICC implemented “Real time ED” patient stratification, this allowed the team to follow up with patients and their families to assess needs right after they returned home from the ED.  The feedback we’ve received on this program from both staff and patients has been tremendous.

This was the 2nd year of the Gaps in Care Campaign; starting late July and looking to wrap up mid-December, the ICC team has made astounding efforts to close our partners and families gaps in care!  As of November 16, 2021, there have been 3,114 Well-Child visits scheduled through telephonic outreach.  In conjunction, we ran a Gaps in Care text campaign alongside the telephonic outreach, we sent a total of 19,576 text messages targeting the W15 measure for Health Choice, Mercy Care plan, and UHCCP.  We contacted over 32, 000 patients/families! 

In 2022 we have amazing things happening!  We’ll be tackling behavioral health discharge follow up, robust patient stratification (including SDoH, BH, Immunizations, and more), practice assignments for the ICC team, and that is just the beginning.  We hope you have the best holiday season and look forward to sharing with you in 2022.

Practice Integration:

In an effort to promote quality improvement and assist our community physicians in achieving their Maintenance of Certification (MOC) requirements, PCCN has established four Part IV MOC projects worth 25 points upon completion.   This year we are pleased to announce that PCCN and PCH have been able to award credits to 16 community physicians who have completed a total of 28 projects.  There are seven more physicians completing their projects this month.  These projects include:

  • AWC: Increasing Annual Adolescent Well-Care Visits in a Pediatric Integrated Care Network
  • W34: Well-Child visits in the Third, Fourth, Fifth and Sixth Years of Life:  Assess children 3-6 years of age
  • DevCh: Developmental Screening in the First three years of life
  • Drowning Prevention

For information on participating in these or other MOC projects, please reach out to your Practice Integration Representative.

New Payer Products:

This year we introduced three new contracting and value-based opportunities for our community providers. As you may recall, PCCN entered into a new value-based contract with Cigna’s Accountable Collaborative Care program. This program is accountable for roughly 20,000 patients through our network and has proven to be an extremely successful partnership. We’ve also messengered an offered two products that are brand new to the market – Medica and Employers Health Network.  These are two new exciting opportunities with new partners that are due to go live on January 1, 2022.

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