Integrated Care Coordination

We provide a personalized, compassionate clinical care and services model for our American Health Advantage of Mississippi Members.

Our model organizes best practices and industry innovations including:

• • A Primary Care Physician (PCP) and an Advanced Nurse Practitioner RN Nurse Case Manager and Clinical Pharmacist care team providing onsite, nursing home-based PCP support for each and every enrolled Member.
  • A risk-assessment tool designed for a nursing home patient population.
  • A comprehensive history and physical assessment that drives an Individualized Care Plan (ICP).
  • A care management platform that helps identify needed preventive health/HEDIS services, ensures the use of evidence-based clinical guidelines, and facilitates care team communications for integrated care coordination.
  • Face-to-face Member interactions that identify Member care preferences and allow time for important care decision discussions and counseling.

Every American Health Advantage of Mississippi Member has a dedicated Nurse Practitioner who is a trusted partner to manage their care by collaborating with the member, member’s family, member’s doctors, and the nursing home staff.

Through close monitoring of our enrolled Members, Nurse Practitioners can identify changes in a Member’s health conditions and quickly determine needs for preventive care.

One of the goals is to avoid unnecessary hospitalizations. Nurse Practitioners can perform tests and treatments normally done in a hospital (such as x-rays, IV therapy and dialysis) at the nursing home where the Member resides.

Our model allows for more comprehensive and coordinated care across medical, social, psychological, pharmaceutical, and economic lines. Our model evolves and adapts to the health care needs of our Members. And, we reduce the burden of unnecessary hospital visits, allowing Members to focus more on the important things in their lives.