Innovative, Tailored Care Models for America’s Seniors
"I regard our care management programs as some of our best innovation work at Martin's Point," said
"Martin's Point is a perfect example of the impact nonprofit, community health plans can have on the communities they serve," said ACHP President and CEO
Martin's Point's takes a strategic approach to delivering care, managing costs and helping seniors live independently. Access to both patient data and health records supports successful care coordination and chronic disease management. Their tailored home-based care model furthers this, bringing comprehensive care to a senior's home and tackling all factors that impact health including physical, emotional, social and environmental. As part of the program, patients are screened for mental illness, addiction and depression. More than half of invited members in the home-care program are accepting nurses into their home for the first visit and then inviting them back. The organization also implemented a pilot program for patients with congestive heart failure, providing in-home assessments, education on symptoms and telemonitoring devices for participants. The effort led to improvements in members' medication adherence by more than 20 percent as well as decreased hospital admissions and a nearly 70 percent improvement in readmissions.
Martin's Point Health Plan is a member of the
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