Health Systems

Our flexible approach to care management, coupled with our revolutionary technology platform, has enabled us to manage programs ranging from several hundred medically complex members to hundreds of thousands of medically diverse members.

CHS has provided services to state Medicaid agencies, hospitals, and universities. We have provided ancillary services to a number of commercial clients as well.

The Goals of CHS Programs

At CHS, we use care coordination activities to generate a patient-centric care plan, which ultimately guides the delivery of safe, appropriate, efficient, and effective care to our members. Our goal is to produce a patient-centric care plan of exceptional quality and high value to the patient, caregiver, care team, and the whole system of care with the following results:

Decrease emergency room utilization.
Reduce the need for inpatient services.
Establish and support the Medical Home concept to members.
Use a culturally sensitive, individualized approach to build resiliency, assist in the achievement of age-related developmental tasks, and promote medical and emotional well-being.
Provide services and support specific to each unique member and their family to help develop the ability to care for themselves or their loved ones at home.
Offer members and families a choice of Medical Home, of unencumbered access to specialty, diagnostic, pharmacy, and hospital providers.
Provide services that promote better outcomes, yet are also cost-effective.
Demonstrate that the Medical Home Network model is an integrated approach that partners the member, the family, the providers, and other natural supports, such as community-based services, into a holistic approach to health care.
Provide a solution for the consolidation and communications of health and health-enablement information to the entire care coordination team that extends from member to primary care physician, ensuring better access to comprehensive health care information.

Government Programs

Community Health Solutions is nationally recognized for our experience, leadership, and results, which enable us to provide innovative and comprehensive medical care management to a diverse client base.

With offices in Florida, Arkansas, South Carolina, and Illinois, CHS is experienced in developing and managing Medical Home Network programs for state Medicaid entities. CHS also has specialized programs for both dual eligibles and medically complex children and adults.

CHS provides

Quantifiable cost savings through implementation of the Medical Home Network (MHN) model
Administrative simplification
Effective strategies for improved health outcomes
Collaborative long-term improvement in program effectiveness and financial results
Performance guarantees
Quality, clinical, and financial reporting consistent with state and federal oversight requirements
Our proprietary health information technology platform, Consensus™, connecting our patients to their providers; we work
with primary care providers to enhance our members’ access to a more patient-centered care system.

Our Medical Home Model

Dual Eligibles

CHS offers senior members enhanced benefits. Senior members receive all Medicare and Medicaid benefits.

Plus:

Access to a nurse by telephone anytime, day or night
An assigned nurse to assist with managing their health or medical condition
Help coordinating doctor appointments
Coordination of needed transportation to medical appointments.

Medically Complex Children and Adults

In 1992, the American Academy of Pediatrics (AAP) published a landmark statement supporting the establishment of a family-centered “medical home” for all children. The conceptual model describes holistic care that is accessible, continuous, comprehensive, compassionate, coordinated, family centered, and culturally effective. CHS supports the AAP in the development of Medical Home Network programs, especially for the most vulnerable of our children. CHS believes that children, as well as adults, with medically complex conditions attain optimal health status when supported in their home and community environment.

We provide home visits by registered nurses who:

Engage members and families in true partnerships during all phases of evaluation, care plan development, and delivery of care
Note the unique strengths and needs of each member and family that affects the design of the care plan
Identify priorities that guide the development of goals and services to be delivered
Ensure families the choice of providers
Report the findings to the Medical Home Provider

Collaborative Care Networks

The success of Collaborative Care Networks is critical to bringing comprehensive, coordinated, and integrated health care services to low income populations.

Section 10333 of the newly enacted health reform law authorizes the creation of Community-Based Collaborative Care Networks. CBCCNs, made up of safety-net hospitals, community health centers, and other safety-net providers, offer coordinated care for vulnerable patients in their areas – increasing health care access and quality.

CHS assists with program formation, administration, and operations including:

Network development
Provider relations – telephonic and field staff
Care/case management – telephonic and field staff
Disease education
Member and provider call center
Claims administration
Quality management

Case Management

The Scope of Our Care Management Program

The CHS Care Management Program incorporates the following activities to promote wellness, facilitate member care, and improve clinical and functional outcomes:

Health risk and disease-specific assessments to identify members with clinical and behavioral risk factors that necessitate case management
Early identification of member clinical risk via data analysis
Early intervention for members with care risk issues via the care coordination program
Early identification of educational needs via data analysis, health risk assessments, and care coordination
Immediate access to the Care Management Clinical Support System via the 24-hour nurse line

Our Care Management department is composed of the Chief Medical Officer, the Manager of Care Management Programs, registered nurse care coordinators, educators, 24-hour triage nurse, and care advocates.

The Six Care Initiatives

The CHS Care Management Program comprises six major initiatives designed to facilitate members’ receipt of necessary, appropriate, and quality care. These initiatives also assure members have access to MHN providers, along with effective and efficient utilization of services and resources. All department personnel serve as facilitators of necessary services for eligible members. They collaborate with the MHN providers to promote wellness through preventative services, education, coordination of services, and monitoring of ongoing care needs of the member.

Care Assessment Initiative

This program implements clinical assessment tools that help MHN providers and care coordinators identify members who have, or are at risk for, chronic conditions and/or complex care needs. It focuses on family medical history, current health status, and behaviors that have an adverse effect on member health.

Care Oversight Initiative

This program provides medical management assistance to members who require hospital or outpatient services. It acts as the liaison between the member, the provider, and/or the facility to promote timely authorization of services.

Care Support Initiative (24-Hour Hot Line)

The CHS Care Management Clinical Support System provides 24/7 clinical support to members and MHN providers via a 24-hour hot line staffed by registered nurses. This program incorporates telephone triage principles, CHS philosophy/goals, and state and federal regulatory compliance requirements in order to support members who need immediate access to a clinical resource or MHN providers who need 24/7 clinical backup availability to facilitate timely and appropriate access to the provider.

Care Education Initiative

The CHS Care Education Program incorporates disease management principles, CHS philosophy/goals, and state/federal regulatory compliance requirements to educate members with complex, chronic conditions. Our education materials focus on improving self-management skills, disease knowledge, and lifestyle changes that promote “healthy lives through healthy choices.”

Care Coordination Initiative

This program incorporates case management principles, CHS philosophy and goals, and state/federal regulatory compliance to facilitate and coordinate the care needs for all members as defined by the provider. This includes children with special health care needs, fragile children with complex care needs, and frail and elderly members with disabilities and/or chronic or complex problems.

Care Analysis Initiative

This program utilizes data for analysis of claims, pharmacy, and Care Management Program information to identify the following: members with complex, chronic conditions; members with variant patterns of utilization; and providers with variant patterns of utilization. Results of analysis may be used to make changes in program initiatives.

Benefits for Insurance Companies, Third Party Administrators, and Self-Funded Groups

Your business is not only competitive but also complex, with many problems to solve. Like many other organizations, you’re probably focused on decreasing costs through improving administrative efficiency, integrated systems, and clinical outcomes. CHS is your SOLUTION! Once implemented, the benefits, both tangible and intangible, will increase your competitiveness and satisfy your clients.

The cost/benefits of case management are well documented. In today’s cost-conscious health care environment, case management must prove its economic value as well as its impact on clinical outcomes.

Care Management Benefits

Tangible benefits may include:

Empowering the physician with information and enhancing their ability to make choices concerning interventions, based on cost-effectiveness and cost-utility information provided by the care manager.
Improvement in management’s ability to assess the cause of adverse outcomes and inefficient processes, and the degree to which treatments, devices, procedures, and interventions are comparatively effective.
Identification and possible elimination of health care delivery service redundancies through claims data analysis.
Reduction in the use of more expensive interventions to achieve the same expected outcome; e.g., use of the emergency room as a primary care setting.
Reduction of readmissions, prolonged length of stays, repeat surgery, and other costs of correction.
Access to 24/7 nurse line, which helps patients access the right care at the right time.
Enhancement of clinical quality through continuous management of process variation, feedback, group process, ownership, and delivery system coordination.

Intangible benefits may include:

Improvement in reporting of credible performance measures.
Improvement in patients’ health literacy.
Improvement in client and patient service and satisfaction, leading to new and retained customers and contracts.
Flexibility in the design of patient services to encompass customer demands.

To learn more or to request a quote please contact us at 1-800-514-7621, or email info@chsamerica.com.