Page 117 - CHHA Binder 2.3.20

4/11/2019

Team Approach to Case Rate Care

Intake Clinical Population
Operations Health

Ensure patient meets Develop plan of care focused Support CHHA at beginning of patient
Process Goals Admit with accurate patient Engage CFM and CUM when Provide utilization and care guidance
episode
admission criteria
on achieving patient goals
Balance patient goals and
during CHHA stay
data
encounters
Manage patient post-CHHA including
community providers
required throughout episode
and transition
Ensure patient has critical DME Conduct DC Oasis accurately and
Transition Goals Inform patient of VNSNY team Inform patient of CUM follow-up role
timely
and
provide MD contact details
Ensure smooth transition to CUM
approach
Each team member’s most important question -
“What can I do today to keep the patient out of the hospital? 9

Important Reminders for Case Rate Patients

 Discuss VNSNY’s team approach to care across full 60 days

 Inform patient that VNSNY Care Manager may call during CHHA
episode and provide care management during the 60-day episode

 Identify/implement patient and family engagement opportunities
 Monitor patient’s progress and obtain input from CFM if extra
services are needed

 Complete the discharge OASIS assessment in a timely and
accurate manner

 Supplies and DME are NOT covered under case rate payment.
(plan will need to authorize)

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