No matter how brilliant the physician, how sophisticated the electronic health IT, or how aligned the incentives, without an engaged individual, nothing much will change in terms of health outcomes. An individual’s needs and beliefs are a critical part of behavioral change, and behavior change is essential for improving health. Yet health care delivery rarely connects in a patient-centered way.
Colorado’s Medicaid Accountable Care Collaborative (ACC) is a central part of Medicaid reform, and Rocky Mountain Health Plans serves as the Regional Care Collaborative Organization (RCCO) for Region 1.
Within the ACC structure, use of multidisciplinary Community Care Teams meets individuals where they are to engage them personally--creating a strong, out-of-the-medical-office relationship. CCTs are comprised of nurses, social workers and other non-medical community health navigators who meet with patients one-on-one to collaborate on the patient's health care goals and support progress in achieving goals, including supporting behavioral change. For some carefully selected patients, community health workers (CHWs) can connect high-risk patients with the services they need. These non-medically trained health workers help individuals make behavioral changes they need to become healthier.
RMHP links traditional health care with services that address patients in an individualized way, closing gaps around social, behavioral, domestic and economic factors that drive utilization, increase costs and contribute to poor health outcomes.
The Comprehensive Primary Care Plus (CPC+) initiative has a strong focus on patient and caregiver engagement. Patient and caregiver engagement is essential function to assist patients in managing their own care. Practices will organize a Patient and Family Advisory Council (PFAC) to help them understand the perspective of patients and caregivers. Practices will use the recommendations from the PFAC to help them improve their care and ensure the practice remain patient-centered.
The Medicaid PRIME pilot includes use of the following Patient Activation Measurement (PAM) objectives: