Meritage Care Management & Care Transitions Services
We offer Care Management and Care Transitions Services to our Meritage patients. Leaving the hospital is a confusing time for patients and their families, and is exacerbated by medication adjustments, new treatment plans, and a need for increased support post discharge. This confusion can lead to patients being out of compliance with their doctor’s orders, missing appointments, or unable to receive newly prescribed and medically necessary durable medical equipment (DME). The Meritage CM team is here to help you receive the highest quality care across the entire care continuum.
Care Transitions Coaching
Our Care Transitions Program is designed to manage transitions from inpatient to outpatient and/or skilled nursing facility sites of care. By doing this, MMN can prevent avoidable readmissions, improve patient safety through medication reconciliation, and improve patient satisfaction by providing better communication and coordination. Care Transitions Coaching follows the Coleman Model™
Complex Care Management
Complex Care Management is designed to help members regain optimum health and improved functional capability, in the right setting, in a cost-effective manner. It involves comprehensive assessment of the member’s condition, determination of available benefits and resources, and development and implementation of a care management plan with patient centered goals, monitoring, and follow up. The Complex Care Management program is for individuals with multiple chronic conditions, limited functional status, and psychosocial needs.
Care Coordination is designed to identify barriers to improving healthcare and matching patients to their needs, reducing care fragmentation. Most importantly, providing patient centered care. Effective care coordination, regardless of patient population, shares four common design elements: assuming accountability for care coordination, providing patient support, developing relationships and standing agreements with key outside providers, and establishing connectivity that ensures appropriate information transfer.
Behavioral Health Care Management provides seamless, efficient professional support to PCPs and specialists in managing assessment, triage and referral for patients with co-morbid behavioral health issues that require intervention.