Extending your Reach for Better Health and Outcomes
Our Complex Care Program (CCP) is a collaborative care model where our nurse practitioners work as an extension of your network doctors. They carry out physician-directed care plans in the comfort of the members' own homes. We focus on a health plan's top 15% of health care utilizers and supplement the care provided by the primary care physician.
Partnership with the Plan & Physicians
Alegis Care will work with the health plan to identify members that could be positively impacted by CCP. Once identified, we work with primary care physicians (PCP) to determine if the member is truly a good candidate. The PCP must agree and provide final authorization for the member to enroll in CCP. Once the member is enrolled, our nurse practitioner will work with the PCP to determine what care can occur in the home.
While in the home, our nurse practitioner will gain some insight into possible health and social issues that the member might be facing. These observations will be shared with the PCP in order to collaboratively develop a revised care plan, if needed.
Our in home care program can be very useful for these members. However, we recognize and respect that the PCP is still fully engaged and accountable for all care decisions.
Members Who Qualify for CCP
Members who qualify for CCP generally have more than 2 hospitalizations and/or more than 3 emergency room visits in the year prior to referral. The members are chronically ill with multiple uncontrolled comorbidities including:
- Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Chronic Kidney Disease
- Diabetes Mellitus
- Coronary Artery Disease
Alegis Care Team
The team that will care for your members is led by a board-certified physician who is supported by in-home nurse practitioners, telephonic registered nurses, and a central Customer Service hotline.
Our doctors and nurses live in the areas that they work. As such, they have developed relationships with other health resources that may be needed for care such as:
- Diagnostic labs
- Home health agencies
- Social agencies