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Catholic Health East has long recognized the increasingly important role of continuing care services in our overall health care system. Nearly three years ago, our Mission and Ministry Committee passed a resolution that continuing care services must be a core ministry of CHE and an integral component of our local ministries. In 2006, CHE launched a system-wide Strategic Planning Process that challenged stakeholders across the system to envision the future of healthcare in the year 2017. Two of the key elements of the 2017 Preferred Delivery Model state that CHE leads in the provision of personal health data and professional advice and support that empowers persons to participate in managing their care and optimizing their health; and CHE provides coordinated integrated care management for persons across the continuum of care. Within our Strategic Plan, CHE articulates its strong commitment to move forward with a care management strategy. CHE's recently-introduced Comprehensive Care Management Model—created and developed with input and direction from Board, Sponsors, and colleagues throughout our System—is a value-based, person-centered, collaborative system of support and caring that promotes health enhancing relationships through efficient and effective care. Comprehensive Care Management connects individuals with information to make informed decisions about providers, services, and programs that support their holistic and spiritual needs throughout their lives. The goal is to optimize each individual's health potential through informed decision-making, effective communication and process facilitation, resulting in the right care delivered in the right setting at the right time. We envision a person-centered model where care is tailored to the individual's current conditions and risks. In the model, the healthcare team empowers the patient to manage his or her own care through the provision of appropriate information, timely guidance and support. Such a model calls for a dramatic transformation in the way care is delivered and requires that clinical information follows the patient and is quickly available both to caregivers and care receivers. The clinical information will be captured in private, personal health records that are owned by the individual and kept secure and available for their use. Payments will be tied to health maintenance and disease prevention, as well as to quality and the outcome of interventions. The transformation called for by the CHE's 2017 Preferred Delivery Model is bold. Elements include universal access to information—regardless of whether or not the provider is a member of the CHE network ; a secure IT infrastructure that enables access by the individual to his or her own personal record and by professionals providing his or her care; integrated care management that provides each person with a written health assessment, multi-disciplinary care plan and the understanding needed to access the broader healthcare delivery system; established linkages with other components of the care system that assure seamless and flawless transfer from one level of care to another; and effective management of chronic diseases and help in coping with the aging process. In Catholic Health East's ideal future health care system, patients are able to make highly informed decisions regarding their health care based on accurate information, unbiased advice and personal preference. Patients receive care that is consistent, coordinated, convenient, compassionate and safe. The key enablers to move from our current health care system to an idealized future are properly aligned financial incentives and interoperable, electronic personal healthcare records. These enablers only will be effective if the interests of the patients are placed ahead of the interests of physicians, hospitals, healthcare systems and payers. Skilled teams of providers working in effective and efficient systems will help patients optimize their health through education, advice, reminder systems, accurate record keeping and therapeutic interventions. CHE hospitals, home care agencies and other care coordination functions will be integrated and positioned to provide clinical advice, telehealth linkages and care management, health planning and care optimization—all IT enabled and protocol driven. This comprehensive care coordination will be person-centered and designed to improve an individual's health from conception to death. The implications of this new health delivery model are significant for our RHCs. We believe that four phases of development—which could take several years to achieve—will be required…including some in-house restructuring of services into a "hub" to allow for better coordination and planning; the introduction of enabling connectivity; the creation of community networks across the continuum of care; and opportunities for regional collaboration among RHCs. You will hear much more about CHE's Comprehensive Care Management Model over the next few weeks and months. I look forward to working with you and your colleagues in building and enhancing our services across the continuum of care and ensuring our continued ability to be a transforming, healing presence in the communities we serve.
Sincerely yours,
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