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An Innovative Community Collaborative. Central Oregon Complex Care Strategy – Centered Around the Patient. Imagine if Rebecca was at the center of multi-faceted coordinated care: Comprehensive 60 minute evaluation – meeting with physician, care manager, and behavioral health specialist
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Central Oregon Complex Care Strategy –Centered Around the Patient • Imagine if Rebecca was at the center of multi-faceted coordinated care: • Comprehensive 60 minute evaluation – meeting with physician, care manager, and behavioral health specialist • Action Plan in her own words – identifying what steps she would take first, and how she would manage in coordination with his responsibilities of his mother • Followup call/email from her dedicated care manager to check in on medications, blood sugars and follow-up appointments • Nutritionist in the same place as her doctor, co-located with her care manager and behavioral health specialist • Emotional support from her health care team Customized Comprehensive Eval Team-based Care Proactive, between visit care Shared Action Plan Actionable data in the hands of caregivers Pharmacy Management Community Collaborative Patient Transitions of Care Socio-behavioral Risk Modification Multi-faceted Approach Patient Education Specialist Coordination Virtual Visits Nutrition Counseling 2 Original slide from Renaissance Health
Complex Care Planning Process Ensuring community trust and engagement in the care partnership is critical
First Order:Getting These Right Original slide from Renaissance Health
Care Model Elements Original slide from Renaissance Health
Contact Information Ken House, Mosaic Medical ken.house@mosaicmedical.com Kate Wells, PacificSource kate.wells@pacificsource.com
