At the heart of Harvard Pilgrim and the Group Insurance Commission’s (GIC) joint Centered Care initiative is the encouragement of improved care coordination, access to care, disease management, data sharing, and analytics. In this ongoing series on Centered Care, we provide information on Harvard Pilgrim’s transition care management programs.
In line with the goals of Centered Care, Harvard Pilgrim provides focused care planning and management for our members, making sure each patient receives the best possible care in the most appropriate settings.
Helping members transition between facilities
When a member requires placement in an acute rehabilitation facility, skilled nursing facility (SNF), or home/community care after being discharged from a hospital, Harvard Pilgrim’s care management team authorizes and coordinates these services.
Our care managers assess the member’s condition, functional capability (e.g., how far the patient can walk, how long he/she can sit up or stand, what his/her cognitive state is), and needs, and then help determine the best setting for continuation of care based on various evidence-based medical criteria.
For patients receiving care in the community setting, Harvard Pilgrim works with the community agency to determine what will be needed in the home, helps orchestrate services, and arranges for the proper durable medical equipment.
Coordination of care
Harvard Pilgrim’s care managers support hospital discharge planners in the coordination of post-hospital care, from the process of reconciling any discrepancies between the medications a patient is taking and those that have been prescribed as part of the treatment plan to post-discharge telephone calls. Such calls are made to recently discharged Harvard Pilgrim members to assure that the member understands the discharge plan, determine whether or not additional services are needed in the home, and ensure that the services that were ordered are in place. Harvard Pilgrim complements the services provided by the staff at all facilities across the continuum of care.
To avoid duplication of services and allow for close coordination of care, Harvard Pilgrim is also beginning to provide provider practices with the list of members receiving services from our Care and Disease Management programs and the status of their participation on a weekly basis.
Harvard Pilgrim aims to constantly improve the management of care for our members, and this commitment is part of what makes us consistently rank among the leading health plans in the nation. We are dedicated to making sure every patient receives exceptional treatment across the continuum of care, according to a well-thought-out and individualized plan.
Look to future issues of Network Matters for additional articles on the Centered Care Initiative.