CareJourney | Leading ACO Care Models 2018-03-01T21:32:48+00:00

CareJourney Codifies Leading ACO Care Models

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Annual Wellness Visits (AWV):
Annual Wellness Visit to discuss care plan for the year

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Chronic Care Management:
Comprehensive care plan for beneficiaries with two or more chronic conditions

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Transitional Care Management:
Follow-up services for moderate- to high complexity inpatient discharges

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Diabetes Prevention Program (DPP):
Clinical intervention model with the goal of preventing type 2 diabetes

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End of Life Planning and Care:
Advance care directives; Home and palliative care

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Collaborative Care Model (CoCM):
Integration of behavioral health care with primary care for beneficiaries with behavioral health conditions

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Accountable Health Communities (AHC):
Provides enhanced clinical-community linkages with unmet health-related social needs

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Million Hearts CVD Risk Reduction Model:
CVD risk calculation and population-level risk management for patients with hypertension

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Shared Decision Making (SDM):
Communication with and education of beneficiaries with preference-sensitive conditions

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Oncology Care Model (OCM):
Bundled payment for episodes of care surrounding chemotherapy administration to cancer patients

Featured Segmentation Model: Rising-Risk (Frailty)

CareJourney implements an open, peer-reviewed patient segmentation methodology published by the National Academy of Medicine that identifies the “frail elderly” as the largest proportion of high-cost patients. CareJourney tracks the frailty segment’s spend performance and produces actionable lists by provider.

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