Centralized Care Management
The Centralized Care Management Team is a small multidisciplinary team working with six community health centers and a Medicaid Managed Care Organization.
The goal of this collaboration is to achieve improved outcomes for health center patients enrolled with the MCO.
HIGH RISK COHORT
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Top 2% spend MCO members
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HFP works with each health center to determine which of these members are appropriate for care management
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HFP team completes outreach to connect patients with their health center PCP and address any other needs
CARE GAPS
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HbA1c Poor Control (>9.0%), Breast Cancer Screening, Well Child visits (age 0-21), Lead Screening (<24 months), Oral Evaluation Dental Services (age <21)
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Utilize Azara to identify members with care gaps
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Outreach to members with open care gaps using Care Message
Transition of Care
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Daily review of HSX for Emergency Department and Inpatient events
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Outreach performed to priority patients (efforts made to avoid duplication)
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HFP team encourages 7-day follow up with PCP and offers patient additional resources when needed
Health Centers We Work With
Philadelphia Department of Public Health-Ambulatory Health Services
1101 Market Street, 8th Floor, Philadelphia, PA 19107
Interim Director, Ambulatory Health Services: Cheryl Kramer, MBA
Phone: 215.685.4758
Family Practice and Counseling Services Network
The Family Practice and Counseling Services Network
4700 Wissahickon Ave, Building D, Suite 118, Philadelphia, PA 19144
CEO: Emily Nichols
Phone: 215.298.0405
Community Health and Dental Care
Coventry Mall | 315 W Schuylkill Rd, Suite G-15, Pottstown, PA 19465
CEO: Bridgette McGivern
Phone: 610-326-9460
www.ch-dc.org
ChesPenn Health Services
125 E. 9th Street, Chester, PA 19013
President/CEO: Susan Harris McGovern
Phone: 610.495.3800
www.chespenn.org
Esperanza Health Center
4417 N. 6th Street, Philadelphia, PA 19140
Executive Director: Susan Post
Phone: 215-302-3600
www.esperanzahealth.org
Delaware Valley Community Health, Inc. (DVCH)
1420 Fairmount Avenue, Philadelphia, PA 19130
President/CEO: Scott McNeal
Phone: 215.235.9600
www.dvch.org
Care Management team site visit with FPCSN Health Annex staff.
Other Projects
Additional Care Management projects include:
Re-SET: Results -- Screening, Early Diagnosis, and Treatment
Meet the Team
Jenny D. Brice, MPH, MFT
Director of Care Management Programs
Julia Galante, BSPH, CCHW
Lead Community Health Worker
Bryana Fisher
Community Health Worker
Maggie Green, CCHW
Community Health Worker/Data Analyst
Kayla Gray, MPH
Special Initiatives Program Manager, ReSET