2.b.iii- ED Care Triage for At-Risk Populations

  • Develop an evidence-based care coordination and transitional care program to assist patients and link them with primary care 
  • Establish linkages with Patient Centered Medical Homes through improved information technology
  • Provide required screening and immediate appointments with primary care
  • Utilize community-based organizations to provide patient education about how and where to receive care

Deliverables:

Care coordination / patient navigation / population health

  • Participating EDs will establish partnerships with community primary care providers with an emphasis on those that are PCMHs and have open access scheduling. All participating PCPs Achieve NCQA 2014 Level 3 Medical Home standards or NYS Advanced Primary Care Model standards by the end of Demonstration Year (DY) 3
  • For patients presenting with minor illnesses who do not have a primary care provider: Patient navigator will assist the presenting patient to receive a timely appointment with a primary care provider, after required medical screening examination, to validate a non-emergency need
  • For patients presenting with minor illnesses who do not have a primary care provider: Patient navigator will assist the patient with identifying and accessing needed community support resources
  • For patients presenting with minor illnesses who do not have a primary care provider: Patient navigator will assist the member in receiving a timely appointment with that provider’s office (for patients with a primary care provider)

Clinical protocols / standard of care

  • Establish ED care triage program for at-risk populations
  • Established protocols allowing ED and first responders - under supervision of the ED practitioners - to transport patients with non-acute disorders to alternate care sites including the PCMH to receive more appropriate level of care (this requirement is optional)

Integration of care / IDS

  • Use EHRs and other technical platforms to track all patients engaged in the project
  • Develop process and procedures to establish connectivity between the emergency department and community primary care providers
  • Ensure real-time notification to a Health Home care manager as applicable

PMO Project Representatives:

Karla Powers- powersk1@mail.amc.edu

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