CCA Vice President of Advanced Clinical Care Alysa Veidis, RN, MSN, FNP-BC, spoke with The Better Care Playbook in a Q&A surrounding the CCA iCMP PLUS program. A partnership with Mass General Brigham (MGB), the iCMP PLUS model uses an interdisciplinary care team to offer home-based care and care coordination to the highest-risk patients enrolled in MGB’s Medicaid accountable care organization.
The Q&A discusses how CCA and MGB identify patients for the program, the typical anatomy of a care team assigned to each patient, and the importance of meeting patients where they are in order to foster accessibility and trusting relationships.
“Our teams are field-based and don’t shy away from seeing the patient on the side of the road, in a shelter, in a coffee shop, or wherever the patient feels safe to see us. Oftentimes, we meet them in the emergency room or in the inpatient setting if they are admitted. These situations provide opportunities to engage with the full care team and continue care coordination as the patient transitions back into the community. This type of collaboration helps prevent readmissions,” Veidis said.