Care Management - Practice Resources
With earlier interventions and preventative care, patients can avoid readmissions to the hospital, reduce out-of-pocket expenses and improve their health outcomes. Practices can improve efficiency, patient satisfaction and adherence. THN is leading the way with convenient, patient-focused chronic care management.
In 2015, the Centers for Medicare & Medicaid Services (CMS) began paying for chronic care management or CCM services for Medicare patients with multiple chronic conditions. THN provides a full range of personalized chronic care management, care coordination, education and support services.
In addition, as part of our unique embedded care coordination model, THN health care professionals work together onsite with a growing number of practices to provide patients with convenient and coordinated support.
Together, we can achieve quality health and wellness outcomes.
Patient Services
Care management is helpful for high-use, high-need patients who may benefit from more intensive care coordination or care management than is typically offered in primary care, family care or a similar setting.
THN collaborates with provider teams to support high-risk patients with:
Our pharmacy assistance and services include:
- Medication review and reconciliation
- Medication education and adherence
- Medication assistance programs: Extra Help and patient assistance programs
- Quality projects
- Drug information for providers and care managers
- Review and enrollment in Medicare Part D plans
Patient Eligibility
Patients with the following qualify for chronic care management or CCM services
- Chronic health conditions with daily management challenges
- Examples include but are not limited to: heart failure, COPD, diabetes and/or depression
- Poor health literacy and/or problem-solving skills
- Multiple medications and/or access issues
- Family health education and/or social support deficits
- Home safety issues
- Social needs requiring referrals to community resources
- Certain mental health conditions and associated needs for long-term mental health planning
Patients THN Serves
THN care management provides services to eligible patients who:
- Are THN ACO flag identified members in the following: KPN tool, Epic or PING
- Have primary care providers who are part of the THN network
- Participate in the following plans:
- Traditional Medicare (Next Gen)
- Humana Medicare
- UHC Medicare and Commercial
- Aetna Medicare and Commercial
- Blue Premier
- All HealthTeam Advantage Members
Patient Referrals
To make a patient referral for THN Care Management and/or Embedded Care Coordination Services, you have several options:
- Enter THN CM referral in Epic
- Complete and fax the patient referral form to 1-844-873-9948
- Call the MD Referral Line at 336-663-5208
- Call 1-844-873-9947 to make a referral
Embedded Care Coordination
As part of its care management offering, THN’s unique embedded care coordination approach to chronic care management or CCM provides patients with access to a team of dedicated health professionals onsite at their primary care provider’s office.
As with other care management approaches, patients receive a comprehensive care plan and the support they need to stay on track for better health.
Our embedded care coordination option allows physicians to:
- Improve care coordination
- Support patient adherence
- Help patients feel more connected
- Sustain and grow your practice
