Federal law permits Accountable Care Organizations (ACOs) such as SRQCN ("CIN”) to implement a waiver of certain health care fraud and abuse laws in order to more fully develop programs, initiatives, and arrangements designed to manage, coordinate, and promote accountability for quality, patient safety, cost, and overall care for patients.
In accordance with federal law, the CIN makes information about its arrangements for which waiver protection is sought publicly available. The CIN Board of Managers has authorized the program described below, has determined that each arrangement is reasonably related to the purposes of the MSSP, and is implementing ACO waivers for the programs described below.
Care Coordination and Management:
The Care Coordination and Management Program through the use of evidence-based medicine and data, finds and engages patients who would benefit from care coordination, navigation and complex case management, including those patients considered rising risk that could become complex in the future and those patients with chronic conditions. The goal of care coordination is to assist the patient to regain or maintain optimum health or improved functional capability. As part of the Program, patients’ needs are assessed, care goals are defined, care plans are developed and then services are provided to assist patients with adherence to their goals and their care plan. The care coordination team supports patients through the use of technology platforms, telephone calls, visits in the patient’s physician’s office and visiting patients in their homes.
Diabetes Chronic Care Management:
The Diabetes Chronic Care Management Program through the use of technology enabled tools assists patients and providers with managing abnormal blood sugars in patients with diabetes. With these tools the CIN aims to improve patient engagement, reduce ED visits, admissions, readmissions, and to improve the long term health of the patient by decreasing secondary complications of diabetes.
Asthma and COPD Chronic Care Management:
The Asthma and COPD Chronic Care Management Program through the use of technology enabled tools assists in managing a patient’s Asthma or COPD. With these tools the CIN will alert the patient’s care team if the patient’s condition is abnormal or worsening. The goal of the program is to reduce emergency department visits, admissions, readmissions, and to improve the long term health of the patient by decreasing secondary complications of asthma and COPD.