{"id":102046,"date":"2016-07-19T12:16:47","date_gmt":"2016-07-19T18:16:47","guid":{"rendered":"https:\/\/93fd47b736.nxcli.net\/QIO\/?page_id=102046"},"modified":"2023-11-09T09:02:00","modified_gmt":"2023-11-09T16:02:00","slug":"resource-team-home","status":"publish","type":"page","link":"https:\/\/dsiohn098w.mpqhf.org\/QIO\/resource-team-home\/","title":{"rendered":"Complex Care Models – Home"},"content":{"rendered":"
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Home<\/strong><\/p>\n

Learn More About Us<\/span><\/a><\/p>\n<\/div>\n

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Resources<\/strong><\/p>\n

Resources<\/span><\/a><\/p>\n<\/div>\n

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Contact Us<\/strong><\/p>\n

Contact Us<\/span><\/a><\/p>\n<\/div>\n<\/div>\n

\"Website\"<\/a><\/p>\n

Super Utilizer Project<\/h1>\n

Mountain Pacific works with communities in Montana to reduce unnecessary hospital readmissions, especially among older adults. Contracted by the Centers for Medicare & Medicaid Services (CMS) to do this work, we have a wide range of partners and stakeholders that helps make sure patients get quality and affordable health care.<\/p>\n

We are now working together to form community outreach teams called Complex Care Models to meet the needs of high-cost, high-needs patients known as \u201csuper-utilizers.\u201d<\/p>\n

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What are Super-Utilizers<\/h2>\n

Super-utilizers are patients that are resource intensive\u2014they have more emergency department visits and more hospital readmissions. These patients also rely more on community services.<\/p>\n

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What are Complex Care Models?<\/h2>\n

Complex Care Models are community health teams that provide care to complex patients needing more primary care and community support services. They also help super-utilizers deal with the social challenges that keep them from getting better care.<\/p>\n

Complex Care Models take care beyond the clinic and hospitals\u2014they provide care to a select set of patients in their home setting.<\/p>\n

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What Type of Patients are Considered<\/h2>\n

Complex Care Models help patients who:<\/p>\n

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  • have had two or more inpatient admissions (within six months)<\/li>\n
  • have had two or more observation stays (within six months)<\/li>\n
  • have had three or more emergency department visits (within six months)<\/li>\n
  • have had six or more urgent care visits (within six months)<\/li>\n
  • can benefit from more coordinated primary care<\/li>\n
  • have medical problems that can be prevented, such as diabetes<\/li>\n
  • are not end-of-life<\/li>\n
  • do not have conditions that will continually get worse<\/li>\n<\/ul>\n

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    Where are we Focusing Efforts?<\/h2>\n

    Helena
    \nKalispell
    \nBillings<\/p>\n

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