Care Management 2.0 Notice

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In 2017, McLaren Physician Partners and the McLaren High Performance Network launched a Transition of Care (TOC) program to serve as the foundation of its Care Management strategy. This program started with notifications to the practices of admission, discharge, and transfer (ADT) activity, progressing to risk stratification of all discharges, and assigning high-risk patients to a Nurse for Care Management. We are continuing to build our program by adding the next layer of services.

“Care Management 2.0” is an extension of the TOC Program and includes not only high-risk patients, but those with rising-risk in a defined disease population. Our focus is to improve compliance with the PCP’s plan of care and promote disease self-management through education, coaching, and removing barriers.

Patients included in Care Management 2.0:

  • Recent hospitalizations with CHF and COPD exacerbation
  • Patients who have been readmitted within 30 days
  • Patients with frequent Emergency Department visits

These patients will be engaged initially through the TOC process and will be followed regularly for at least 30 days. A well-coordinated, safe transition with ongoing support will ultimately reduce avoidable utilization and improve overall outcomes for your patients.

Care notes will be sent to the PCP office via preferred mode of communication.

Key Messages

  • Population includes Medicare FFS (ACO) and Medicare Advantage:
    1. Patients discharged with CHF, COPD
    2. Patients who have been readmitted in the past 30 days
    3. Patients with frequent ED utilization
  • “Care Calls” will be initiated post-event (ED/hospitalization TOC) to establish an extended relationship with the patient.
  • The average time of engagement will be 30-days post triggering event. Timeframes will vary based on varying needs of the patient.
  • Care Management will contact the PCP/office if the patient has needs requiring physician input or medical decision-making.
  • Summary documentation will be provided monthly via preferred mode of communication.
  • Care calls will be documented in a manner compliant with CCM standards and billing requirements however, CCM is not billable within 30-days of a billed TCM.
  • If you have questions related to billing TCM or CCM and part of an employed practice, contact Jessie.Korte@mclaren.org or Jade.Green@mclaren.org. If part of an independent or private practice, contact Andrea.Phillips1@mclaren.org.
  • CPC+ practices will continue to manage their population; the ACO Care Management team will provide this service to all others.

For additional information or questions, please contact Andrea Phillips, Director of Care Coordination, Andrea.Phillips1@mclaren.org or by phone (248) 484-4947.