McLaren Physician Partners (MPP) and McLaren High Performance Network, LLC (MHPN) have continued an exciting Care Management expansion over the past quarter. In addition to Patient Navigators, we now also have Registered Nurse Care Managers and two Masters prepared Social Workers on board to help connect your patients to the appropriate level of assistance.
As a department, our goal is to improve the overall quality of care and outcomes while reducing avoidable utilization. Our Care Coordinators provide Transition of Care and Chronic Care Management services for high-risk patients. These patients are assessed for ongoing care management that includes: education on self-management techniques, access to care, financial concerns, transportation, home health care or assistance, inadequate housing or food, and other social and medical problems that affect the patient’s health.
Targeted patients are identified through analytics using disease classification and utilization patterns, focusing on those at high-risk for readmission, who may need intervention to ensure they receive care in a more appropriate setting, or who may just need extra assistance navigating the health care system.
We appreciate all the assistance our physician partners provide in bridging the gaps in care that we have identified, such as the need for home care, follow up appointments, medical insurance coverage, and medication concerns. We also appreciate referrals for your Medicare Fee for Service and Medicare Advantage patients who you feel would benefit from these types of services and ask that you continue to refer these patients to us.
Referrals can be made using one of the following methods:
For additional information or questions, please contact Andrea.Phillips1@mclaren.org or call (248) 484-4947.