Team Training: Physician Care Alliance provides team training for patient-centered coordinated care including pre-visit planning, shared decision-making, patient engagement and patient experience activities. Training includes risk stratification, data-driven population-based outreach, quality measure improvement, care management, utilization, and total cost of care. Additional PCA training and tools include provider and team clinical campaigns, care gap closures, clinical decision support, patient recall methods, and medication management and reconciliation.
Care Coordination and Transition Programs: PCA provides Care Coordination and Transitional Care Program training and resources. These programs reduce hospital readmissions and clinical complications as well as improve outreach during the patients' recovery. Training components include follow-up appointment scheduling, post-discharge phone calls and home visits, and scheduling medical services. Additional post-discharge services include education and tools for medication reconciliation, caregiver support, care planning, and home safety checks.
Community Care Coordination: PCA training helps develop a team approach to care coordination that involves other professionals such as care managers, mental health counselors, social workers, and system navigators. The community-centered service delivery model builds collaboration with medical specialists, behavioral health providers, and facilities to coordinate care throughout all settings.
High-impact Ambulatory and Home Programs: PCA provides strategy support and training for a high-impact ambulatory program to reduce avoidable admissions and readmissions, reduce inpatient stays and non-urgent emergency department visits, and improve end of life quality through in-home care. Training includes identifying high-risk and medically fragile patients, use of technology enablers such as virtual visits and remote monitoring, and telephonic consults. PCA team training includes an engagement program for nurses, community health workers, and community support. Education includes medication reconciliation, evaluation, case management, counseling, and end of life planning.
PCA’s Avoidable Day Management program assists high-risk patients with social, home, and family barriers. This training program is coordinated with the Care Management team to educate and manage patient and family expectations and to strengthen communication processes.
Extended and Intensive Care Management: PCA’s Extended Care program for home and sub-acute settings focuses on short-term transitions of care (three months or less) following hospital discharge. Training emphasizes provider-to-patient and provider-to-provider communication and planning. Education and tools define patient goals, appropriate level of care transition, monitoring of length of stay, readmission, quality care, and care gap closures. Training for Intensive Care Management identifies high-risk, high-cost patients and includes disease management, transitions from and between care settings, and post-facility discharge calls.
Enhanced Patient Services: PCA training for Wellness Coaching helps to improve the quality of care and substantially reduce the total cost of care. PCA’s emphasis is on preventative and non-medical adherence programs (e.g. smoking cessation, weight loss, exercise) as well as chronic disease education.
Population Health: Population health software and training facilitates train-the-trainer programs for data aggregation and analysis, care gap campaigns, quality program alignment, and bundled disease measures. Training includes pre-visit planning, workflow, patient outreach and engagement activities. Education covers provider panels, patient attribution, high-risk patient identification, and complex and chronic disease quality measures for tracking and trending. Based on data availability, analytics may include pharmacy utilization.
Value-Based Care Education: PCA provides physician and team education for value-based health plan contracts incorporating collaboration for improved health insurance partnerships and quality health care outcomes. Training also includes Medicare and commercial risk coding and workflow.
Analytics and Risk Management: PCA provides data analytics support and reporting for clinical performance and quality outcomes at the provider, clinic, and network level to meet health plan requirements including shared savings contracts.
Network Management: PCA negotiates commercial payor agreements and provides contract advocacy and quality metric modification to support sustainability. Additionally, PCA coordinates with health plans on behalf of providers to obtain rosters, patient attribution information and updates.
Evidence-Based Committee Facilitation: Physician Care Alliance committees facilitate the use of evidence-based guidelines to incorporate the standard of care and best practices for clinical quality, utilization, population health, care coordination, and practice transformation.