Ascension Saint Agnes Community Health Partners Care Transformation Organization leverages significant experience in implementing patient centered workflows with care management expertise to support providers in reducing unnecessary utilization while improving both the patient experience and quality of care. Our in-person care management team assists patients in managing complex chronic conditions, address health related social needs, and provide behavioral health therapy and connection to services. Furthermore, CTO staff utilize data-driven strategies to analyze utilization patterns to advise practices on opportunities for improvement and best practices.
Ascension Saint Agnes Community Health Partners CTO utilizes a multidisciplinary approach to address patients' complex chronic conditions, social determinants of health, and continuity of care barriers. This triad model consists of a registered nurse, social worker, and care coordinator to individualize the care plan based on the needs of each patient. We are able to work with practices to customize care management to support their needs.
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Ascension Saint Agnes Community Health Partners Care Transformation Organization’s interdisciplinary team includes access to the MDPCP Pharmacist. Our dedicated pharmacist collaborates with members of the care team to provide medication expertise and optimize medication therapy. They also partner with patients to ensure patients understand their medication regimens and feel confident taking their prescriptions.
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Ascension Saint Agnes Community Health partners supports practices in implementing effective screening workflows for social determinants of health. Our interdisciplinary case management team connects patients to our network of community resources to ensure the best health outcomes. Depending on the patient's needs varying levels of community resource coordination are available.
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By using best practice frameworks, we can successfully guide our practices through their care transformation activities. Our focus on healthcare quality and process improvement allows us to provide operational support and training prioritized based on individual practice needs. In addition, we leverage various data sources including EMR and claims data to identify patients who would benefit from care management, monitor utilization, and quality of care.
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