Centralized Care Management
The Centralized 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
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
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
Yudy Calixto, CHW
Community Health Worker
P: 215-246-5448
Julia Galante, BA
Community Health Worker
P: 215-567-8001
C: 215.971.2256