Integrated Care Coordination

Our integrated care coordination model promotes increased communication and collaboration between care settings for patients. We use technology and people to reach out to and engage PCPs, hospitals, pharmacies, home health, and caregivers to ensure that patient information is readily available and updated as care levels and care settings change. Our NFists, who are dedicated physicians, are an important and unique part of our integrated care coordination model.  NFists work in close collaboration with our Advanced Nurse Practitioners, who act as care navigators for patients across the care settings.

Some of the most vulnerable patients travel through post-acute facilities or receive some type of long-term care—AllyAlign Health makes sure that these complex patients don’t fall through the cracks during transitions or become victims of multiple, disjointed care efforts.

Innovative technology tools:

  • Align360 platform connects the care team—including plan care management—and allows for monitoring and reporting of care plans, assessments, and quality metrics across all network providers

  • ReferAlign aids with identification of network providers and allows for direct referrals to the network

  • WellnessAlign captures Annual Wellness Visit information, accurately codes HCCs, and securely transmits the RAF scores to the Plan

  • Combined with onsite care, these tools extend the reach of the plan care management team and support CMS Model of Care requirements

Outcomes:

  • Referral management: concentration of skilled volume into preferred facilities

  • Management of total cost of care for custodial population

  • Reward for investments in quality and reductions in cost

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