Care Management

As a practice within the OhioHealth Group Clinically Integrated Network (CIN), you have access to and can benefit from clinical programs that are designed to improve patient health and produce efficiencies in patient care delivery.

Leadership within OhioHealth Group (OHG) and practicing OhioHealth Group CIN physicians are leading the charge to create evidence-based guidelines and meaningful clinical interventions – some of which are listed below. We are also working with vendors to explore new technologies, like Johns Hopkins’ ACG System, which can predict patients’ health over time using a variety of data touchpoints. The care management and pharmacy teams support the programs listed below.

 

Emergency Department (ED) Utilization
As we continue to explore ways of reducing inappropriate use of EDs, this program seeks to educate patients who visit the ED more than twice in six months and connect them with appropriate resources, such as a Primary Care physician or Urgent Care.

 

Transitions of Care
This program is designed to reduce avoidable readmissions within 30 days post-discharge through hands-on coordination of care, education and leveraging evidence-based guidelines across the continuum.

 

Chronic Disease Care Management
Our care management program is expanding, from a high-risk patient focus to one that also encompasses low and rising-risk patient populations where our opportunities to make significant strides are greatest. Their efforts will focus on multiple conditions, including chronic heart failure (CHF), chronic obstructive pulmonary disorder (COPD) and chronic kidney disease (CKD).

 

Diabetes Care Management
This program includes the Diabetes Prevention Program, which attempts to prevent progression of patients with prediabetes, and extends to comprehensive management of those with diabetes and associated conditions.

 

Medication Therapy Management
This program is designed to help patients effectively manage their medications through a partnership between you, your patients and OHG’s clinical pharmacists. Click here to learn more about how this program works.

 

While these programs are in various stages of development and implementation (some are active now), the hope is that, in the near future, all will be scaled across the network. For more information about these programs, please contact OHG at 614-566-0003 or 877-644-7469 (toll free).