Partners in Care Foundation secured a partnership with a local medical provider to develop a model of transitional care management and chronic care management focusing on addressing the Social Determinants of Health for the target population. The group received grant funding to develop and implement a model for delivering transitional care management and chronic care management to demonstrate the model’s sustainability.
This webinar provides an overview of the project, defines the opportunity and describes the process necessary to implement a model of care delivery that integrates a community-based organization (CBO) with an established medical provider.
Timothy P. McNeill, Health Care Consultant
Sandy Atkins, Vice President of Strategic Initiatives, Partners in Care Foundation
• Describe the CMS federal policy changes that enable CBOs to work with medical providers to deliver services that can be contracted to the CBO, as a third-party entity;
• List the specific billing codes, national reimbursement rates and requirements to deliver the defined services;
• Describe the process planning required to deploy the integrated model of care;
• Identify business planning requirements to deploy the integrated model of care to reach the medical provider’s and CBO’s financial sustainability requirements and
• Describe the impact of proposed changes to the requirements that will support the expansion of medical provider and CBO partnerships to deliver a range of services.