Centralized Care Management

Care Management

 

The Centrazlied Care Management Team is a small multidisciplinary team working with six community health centers and a Medicaid Managed Care Organization. The goal of this collaboration is to achieve improved outcomes for health center patients enrolled with the MCO .

HIGH RISK COHORT

  • Top 2% spend MCO members
  • HFP works with each health center to determine which of these members are appropriate for care management
  • HFP team completes outreach to schedule patients with their health center PCP 

CARE GAPS

  • HbA1c Poor Control (>9.0%), Annual Dental Visits, Breast Cancer Screening, Well Child visits (age 0-21)
  • Review care gap data from United with the health center
  • Perform chart reviews using i2i Tracks
  • Explore outreach options to close care gaps

Transition of Care

  • Daily review of HSX for Emergency Department and Inpatient events
  • Outreach performed to priority patients (efforts made to avoid duplication)
  • HFP team reviews discharge instructions with patients and encourages 7-day follow up

Health Centers We Work With

Philadelphia Department of Public Health-Ambulatory Health Services

1101 Market Street, 8th Floor, Philadelphia, PA  19107

Interim Director, Ambulatory Health Services: Cheryl Kramer, MBA

Phone: 215.685.4758

www.phila.gov/health/AmbulatoryHealth/

Family Practice and Counseling Network

The Family Practice and Counseling Network

4700 Wissahickon Ave, Building D, Suite 118, Philadelphia, PA 19144

Network Executive Director: Emily Nichols

Phone: 215.298.0405

www.fpcn.com

Community Health and Dental Care

Coventry Mall | 315 W Schuylkill Rd, Suite G-15, Pottstown, PA 19465

CEO: Bridgette McGivern

Phone: 610-326-9460

www.ch-dc.org

ChesPenn Health Services

125 E. 9th Street, Chester, PA 19013

President/CEO: Susan Harris McGovern

Phone: 610.495.3800

www.chespenn.org

Esperanza Health Center

4417 N. 6th Street, Philadelphia, PA 19140

Executive Director: Susan Post

Phone: 215-302-3600

www.esperanzahealth.org

Delaware Valley Community Health, Inc. (DVCH)

1420 Fairmount Avenue, Philadelphia, PA  19130

President/CEO: Scott McNeal

Phone: 215.235.9600

www.dvch.org

Meet the Team

Shakira Gerald, MSW, LSW

Manager of Care Management

P: 215-567-8001

C: 215-977-8009

E: sgerald@healthfederation.org

Yudy Calixto, CHW

Community Health Worker

P: 215-246-5448

E: ycalixto@healthfederation.org

Julia Galante, BA

Community Health Worker

P: 215-567-8001

C: 215.971.2256

E: jgalante@healthfederation.org