The Pacific Business Group on Health (PBGH) is receiving a CMS Health Care Innovation Award to work with various provider groups and health plans in rural and urban counties throughout California to improve care coordination for 30,000 Medicare and dual-eligible Medicare-Medicaid beneficiaries at risk from multiple chronic conditions. The Intensive Outpatient Care Program uses well trained care managers embedded in high-performing primary care teams to develop close relationships with medically complex patients and deliver highly individualized and accessible primary care, based on treatment goals specific to each patient. The goal is fewer emergency room visits, a reduction in avoidable hospitalizations, better mitigation of disease, and reduced complications as a result of intensive care management. The grant will enable PBGH and California Quality Collaborative to provide a technical assistance program for 17 provider systems in California to introduce and spread intensive care management for high-risk Medicare beneficiaries across their networks of 9,000 primary care practices. The goal is to reduce the cost of care five percent for these beneficiaries while improving their health and patient reported experience with care by at least two percent annually.
