Care Coordination

CCQP ACO Waiver Protection Form

Program Name:               
Care Coordination

Type of Waiver Utilized:
ACO Participation Waiver

All Parties Involved:      
Christiana Care Quality Partners Accountable Care Organization (CCQP ACO)
Christiana Care Health System & The Medical Group
Bayhealth Medical Center, Inc. & Bayhealth Physician Alliance
Nanticoke Health Services & Nanticoke Physician Network
All participating private physician practices

Date Program will begin:
January 1, 2016

Description of Arrangement:
Christiana Care Health System employs an inter-professional care coordination team referred to as Care Link.  This group includes RN Care Coordinators, Pharmacists, Social Workers and Medical Directors.  The focus of this group is to assist patients to receive the right care in the right place at the right time.  They contribute to this goal by:

  • Assisting with Transition of Care services following a patient hospitalization
  • Coordinate required support services with physician offices, hospital facilities, post-acute facilities, home care providers and healthcare suppliers
  • Reviewing medication for high-risk patients and prompting physicians to consider changes when something seems duplicative, inappropriate or missing
  • Helping patients receive the services they require to live with chronic conditions
  • Prompting patients and providers when a patient is due for preventive services

To contribute to the improved health of beneficiaries cared for by CCQP ACO practices, Care Link services will be extended to all participating physician practices and facilities.

Purpose of Arrangement:
The purpose of this arrangement is to coordinate and facilitate care across various providers in order to reduce unnecessary utilization of healthcare services.  Examples would include ensuring patients are able to follow up with the primary care physician soon after discharge to reduce the risk of readmission or helping a patient find a particular type of provider when they are not sure how to do so themselves.

Items, services, facilities or goods covered by the arrangement:
Care Coordination services as outlined in Description

Date and manner of the Governing Body’s Authorization:
Approved by the Board of Managers on 7/29/2015