Program Overview

This new program is for organizations seeking a better approach to support their Medicare, medically complex population.  The program takes a person-centered approach, providing training, tools and resources to address all aspects of older persons’ lives—medical, behavioral, social, environmental.  

Program Benefits:

1. Regional Action Communities: Four in-person learning sessions over 12 months to guide delivery system leaders through developing, launching, or expanding person-centered care programs within their own organizations.

2. Care Coordinator Training: Local 2.5-day skills-based training program with an emphasis on techniques supportive of person-centered care, such as motivational interviewing and shared agenda setting.

3. Intensive Technical Assistance: For program leaders and care coordinators, including elbow-to-elbow coaching sessions at practice sites.

4. Implementation Toolkit: Online toolkit describing steps and tools to build a sustainable primary care-embedded, person-centered care program for medically complex Medicare patients.

5. Budget and Sustainability Planning: Business case development for person-centered care, using the Return on Investment Calculator developed by The SCAN Foundation.

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* 1. Name of organization

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* 2. Do you currently have improvement activities targeting medically complex older adults?

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* 3. Please describe how you identify and risk-stratify your medically complex population.

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* 4. Do you use person-centered techniques with your medically complex population?

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* 5. What challenges have you faced in developing programs for the medically complex?

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* 6. Are you currently participating in any practice improvement collaboratives, or programs that involve multiple organizations or groups?

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* 7. How will our collaborative to strengthen person-centered care support your strategic goals for improving the care of medically complex older adults?

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* 8. How many physicians are part of your organization?

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* 9. In which counties do you operate?

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* 10. Please indicate the number of Medicare patients you serve by category:

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* 11. Please provide your contact information:

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