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NDHI NAT IONAL DIALOGUE FOR Healthcare Innovation Care Coordination Organization Overview • Mayo Clinic is an internationally-recognized nonprofit organization committed to clinical practice, education and research, providing expert, whole-person care to everyone who needs healing • The organization serves over 1.3 million patients each year through its major campuses in Minnesota, Arizona, and Florida, and at its Mayo Clinic Health System locations in over 70 communities in Minnesota, Wisconsin, and Iowa • Mayo Clinic aims to provide the highest quality care to every patient through integrated clinical practice, education, and research Background Patients with chronic conditions have complex care needs. When these needs are not fully met, these patients are at higher risk for hospitalizations, medical interventions, and overuse of high-cost emergency services. Mayo Clinic believes that healthcare systems can do more to engage patients and enable them to take an active role in both wellness and disease management. To fill this unmet need, Mayo Clinic implemented the Care Coordination model to address high-risk patients with chronic conditions or other serious health conditions. Rather than focusing on disease-specific care, Mayo Clinic believes in addressing the whole patient and his or her spectrum of conditions. Care Coordination provides intensive, individualized services to these patients, with the following goals: • Improve health status • Proactively manage complex medical conditions • Increase capacity for self-management • Coordinate services among multiple providers • Reduce need for unnecessary services Program Details • Patients with complex health conditions are referred to the program and screened for disease complexity, psychological and social concerns, as well as utilization of community resources • Once a high-risk patient is identified and enrolled into the program, a registered nurse (RN) care coordinator is assigned and works with the patient to: –– Ensure proactive communication and coordination between all care providers –– Develop a patient-centered plan of care with the patient, family, medical providers, and community providers –– Track the patient’s progress against his or her care plan and follow up regularly –– Provide education and self-management support –– Work with patient and provider to proactively address symptoms An Initiative of the 77 | Care Coordination
NDHI NAT IONAL DIALOGUE FOR Healthcare Innovation • All patients at Mayo Clinic are also assigned a broader care team, including: –– Primary care physician -- Leads the care team by guiding clinical decisions and offering expertise about complex care needs –– Nurse practitioners and physician assistants -- Perform acute care and chronic disease management -- Coordinate with physicians for healthcare planning –– Licensed practical nurses, medical assistants, and clinical assistants -- Prepare patient for care visits -- Arrange preventive programs and social services –– Other relevant roles that vary by case, such as social workers, mental health providers, and pharmacists Value Delivered • Engages the patient in care management • Improves patient’s health status over time • Leverages all care providers’ skills to balance patient care across the team Path Forward Care Coordination requires new workflows and processes, as well as a mindset shift toward collaborative care management. Mayo Clinic is committed to embracing and facilitating these changes, in order to deliver truly coordinated care. The health system is also exploring the implementation of new technologies, such as remote monitoring and telemedicine, to minimize coordination gaps and enhance patient convenience. Although medical evidence supports the importance of moving to new care models, reimbursement has been slow to evolve. Mayo Clinic is committed to providing enhanced primary care services and will continue to work with payers in the development of reimbursement models that fairly compensate primary care practices. Care Coordination | 78
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Foreword The U.S. healthcare indust
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Section 1 Collaborations to Enable
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