The use of technology by care teams is helping to improve the management of care for patients covered by Inland Empire Health Plan in California, which serves 1.25 million residents in Riverside and San Bernardino counties.

Inland’s efforts were recognized through an innovation award from the California Department of Health Care Services for its improved management of covered members. The annual award recognizes creative interventions by Medi-Cal plans seeking to improve the quality of members’ care with a focus on using best practices.

Inland Empire Health Plan provides funds to a dozen healthcare organizations with 30 participating clinics to develop care teams that include a behavioral health clinician, nurse care manager, care coordinator and a primary care physician champion. The teams manage a caseload of patients with chronic medical, mental health or substance abuse conditions.

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“Many members who have a chronic medical condition coupled with either a mental health or substance abuse disorder have been receiving fragmented care that has not adequately addressed their behavioral health needs,” says Jennifer Sayles, MD, chief medical officer at Inland Empire Health Plan. “This program integrates care across multiple providers and healthcare systems, improving members’ health outcomes while reducing their use of emergency rooms and urgent care clinics.”

For example, under its Behavioral Health Integration and Complex Care initiative, Inland Empire assigns “practice coaches” to further support physicians in adopting data analytics that include predictive risk modeling to identify the most complex or high-risk individuals in each practice.

The practices also learn how to use a registry to collect health and behavioral outcomes to assess which patients are progressing and which are not. In the past 18 months, participating patients have significantly decreased blood pressure and depression disorders, an analysis of the program shows.

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