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FPP involved in two new care coordination demonstration projects

Mike Bonazzola, MDStarting this fall, the OHSU Faculty Practice Plan (FPP) will begin two pilot care coordination delivery model programs. The first project is a partnership between the faculty and staff of the departments of Family Medicine and Medicine with the Health Leadership Task Force – a consortium of Oregon businesses and health plans.

Called the “High Value Patient Centered Care Model,” patients will be invited by their health plans to enroll in the two-year demonstration project. The enrolled patients will receive the same services and see the same physicians as before; however, these patients will also be assigned to work with a dedicated RN care coordinator on a comprehensive plan for maintaining their health. A crucial difference from previous insurance company-led efforts is that the care coordinator will be a member of the primary care team and located in the clinic.

"Care coordination is a particular challenge for people with complex chronic conditions who receive care from multiple specialists and providers," said Mark Richardson, MD, MBA, Dean, School of Medicine and President, FPP. "Evolving types of delivery models have the potential to improve patient outcomes and lower costs."

While the prevailing practice of public and private health plans has been to reward interventions – not prevention or outcomes – this care coordination model may provide data on the effectiveness of alternative care models on patient outcomes and on future payment reform. An independent third party evaluator will report on the results at the one- and two-year marks by comparing the outcomes and costs with a non-participating control patient group. In addition to receiving a flat per-person payment, the FPP will share in the health care cost savings, if any, after a two-year period.

The second project is for OHSU employees who receive their health care through either the OHSU PPO or 250 health plans. This initiative has as its focus employees whose complex chronic conditions require a high degree of health care and who will most immediately benefit from a coordinated health care plan. The program will also be evaluated at both the one- and two-year marks.

"Both initiatives will enhance our care of patients. Care coordination is a key method to improve the outcome of our care, while improving the patient experience," said Scott Fields, MD, MHA, Professor and Vice-Chair, Department of Family Medicine.

The employee program is modeled on the Care Management Plus (CMP) program which was, in part, developed by David Dorr, MD, Assistant Professor, Department of Medical Informatics & Clinical Epidemiology. Dr. Dorr was part of a team that conducted a CMP study between 2002 and 2005 at 13 primary care clinics in Utah. The study found that there were significant health benefits and fewer hospitalizations with increased care coordination. Development of the CMP model was supported in part by the John A. Hartford Foundation.

For both projects, using an electronic health record to track a patient’s care is an essential tool of the model.

Pictured: Mike Bonazzola, MD, FPP Chief Medical Officer and Assistant Professor, Department of Medicine, is a faculty leader on these initiatives. 

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