Lesson Transcript
InstructorColleen LeveretteShow bio
Colleen is a certified rehabilitation counselor and has a master's degree in rehabilitation counseling and an Ed.S. in counseling.
Models of care are often used in settings that provide medical and case management services. Case managers must be knowledgeable of models of care such as the Home Health Model, the Chronic Care Model, and the Special Needs Plan. In this lesson, we will explore the basics of these models.Updated: 10/23/2022
Table of Contents
- What Is a Model of Care?
- Health Home Model
- Special Needs Plan
- Chronic Care Model
- Lesson Summary
Models of care are used in a variety of healthcare settings to provide guidance and direction on how to successfully deliver services to the population served. Many case managers work in healthcare settings such as home care, nursing homes, and hospitals, and provide services such as resource management, service facilitation, and advocacy. For medical and healthcare facilities or agencies and their case managers to successfully provide services to their clients or patients, they examine, select, and implement models of care. Some of the most commonly used models of care are the Health Home Model, the Special Needs Plan Model, and the Chronic Care Model.
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The Health Home Model is also referred to as the Patient-Centered Medical Home Model (or PCMH), the Advanced Primary Care Model, or the Primary Care Medical Home Model. The following are the defining features of this model:
- Accessible
- Committed to quality and safety
- Coordinated
- Patient-centered
- Comprehensive
The accessible feature of this model means that the services the healthcare entity provides are readily available to patients. This can include 24/7 telephonic access to certain services and information, after-hours help, telehealth options, and shorter wait times. The component of this model committed to quality and safety places an emphasis on the health entity prioritizing quality improvement and the informed choice of patients and their families. The coordination aspect of this model refers to the collaborative efforts needed to provide the best quality care to patients. This includes collaborating with organizations that provide specialty care, other hospitals, and community or social agencies.
The home health model is patient-centered because it values the needs, best interests, and autonomy of patients. This is visible in the decision-making process that occurs during the pre-treatment, treatment, and post-treatment processes and involves collaboration between patients, support systems such as families, medical staff, other organizations and agencies, etc. Lastly, it's comprehensive because it involves the coordination of interdisciplinary services such as mental health, acute care, and prevention that are needed to provide the adequate care for patients.
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A Special Needs Plan (or SNP) is a plan provided by the Centers for Medicare and Medicaid Services (CMS) that is specially designed for individuals who are institutionalized, have a chronic condition that is disabling or severe, or someone who is dual eligible. Accordingly, the three SNP plans are Chronic Condition (C-SNP), Dual Eligible (D-SNP), and Institutional (I-SNP). It's important to note that individuals who qualify for this type of plan must fall under the Centers for Medicare and Medicaid Services' (CMS) definition of special needs. All types of Medicare Advantage (MA) care coordinated plans (CCP) cover SNP plans.
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The Chronic Care Model is a comprehensive model that's designed to address the needs of those with chronic conditions such as cancer, heart disease, and diabetes. This model places an emphasis on the inclusion and coordination of the following aspects of a healthcare process:
- Decision support
- Clinical systems design
- Self-management support
- The community
- Delivery systems design
- The healthcare system
It's important to note that the application of the Chronic Care Model or any of the other previously-discussed models will be tailored to fulfill the needs, goals, and missions of each healthcare entity or facility.
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All right, let's now take a moment to review. There are several models of care that can be used by agencies that provide medical and case management services. The Home Health Model is also known as the Patient Centered Medical Home (PCMH) Model, the Advanced Primary Care Model, or the Primary Care Medical Home Model. The model is accessible, committed to quality and safety, coordinated, patient-centered, and comprehensive.
The Special Needs Plan (SNP) is a plan provided by the Centers for Medicare and Medicaid Services (CMS) that's specially designed for individuals who are institutionalized, have a chronic condition that is disabling or severe, or someone who is dual eligible. The three SNP plans are Chronic Condition (C-SNP), Dual Eligible (D-SNP), and Institutional (I-SNP).
Finally, the Chronic Care Model addresses the needs of those with chronic conditions such as cancer, heart disease, and diabetes. It involves the integration of these elements: decision support, clinical systems design, self-management support, the community, delivery systems design, and the healthcare system.
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