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A high-touch, team-based clinical model addresses everything from high blood pressure to loneliness.
ABSTRACT Older adults and others with complex and high-risk medical conditions often lack access to the coordinated care they need to properly manage their chronic issues, resulting in hospitalizations and more spending on treatment. CareMore Health, an integrated values-based care delivery system that provides care to Medicare and Medicaid beneficiaries, focuses on caring for the frailest populations by harnessing the power of teamwork to treat its patients' medical, social, and personal health needs. By investing in prevention, early intervention, education, and partnerships with community-based organizations, CareMore Health achieves fewer hospitalizations, bed stays, and overall better health outcomes for patients compared to beneficiaries covered under fee-for-service Medicare. | key words: CareMore Health, Care Center, integrated care, Togetherness Program
CareMore Health originated twenty-five years ago as a medical group, and employs a proactive righ-touch clinical model focused on prevention and education. Founded and led by physicians, the organization is a care delivery system for Medicare and Medicaid beneficiaries that uses an integrated delivery model to provide an individually tailored holistic approach, including chronic disease management, through highly coordinated care. By addressing patients' medical, social, and personal health needs, the resulting clinical outcomes rank well above the national average.
The CareMore Health delivery system was created to care for the most frail, costly, and often underserved patients by proactively identifying and managing specific health needs. Many older adults suffer from chronic disease, and approximately 44 percent of CareMore's patients are enrolled in Medicare Advantage Special Needs Plans (SNP) tailored to treat specific and often chronic health conditions such as diabetes, heart disease, and respiratory ailments. Other SNPs address health and economic status, such as dual eligibility for both Medicare and Medicaid programs (D-SNP) and those patients requiring institutional care.
While also addressing social and psychological health needs, CareMore Health provides specialized programs to help older adults better manage health conditions such as congestive heart failure, chronic kidney disease, end-stage renal disease, chronic obstructive pulmonary disease, diabetes, and more. To provide proactive care and better care management of such conditions, high-risk patients are identified early on, and CareMore staff communicate with them often (depending upon level of need), via telephone and in-person interactions at a...