Person Centered Practice, Care Coordination and the Interdisciplinary Care Team

Person Centered Practice

The concept of person centered practice – keeping the patient at the center of the care planning and decision-making process – is integral to MMAI, ICP, FHP and MLTSS. By focusing on each individual’s personal needs, wants, desires and goals, person centered practice promotes choice, purpose and meaning in daily life for MMAI, ICP, FHP and MLTSS members.  

From the provider perspective, person centered practice refers to primary health care services that are relationship-based with an orientation toward the whole person. A person centered practice is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute and chronic care.  

BCBSIL supports the Primary Care Medical Home Program (PCMH) which is a health care setting that facilitates collaboration between patients, their families and a health care team including physicians, nurses, counselors, social workers, behavioral health providers and other health care professionals as needed. In a PCMH, patients actively participate in decision making, and feedback is sought to guarantee patients’ expectations are being met. Evidence-based medicine and clinical decision support tools guide decision making. Care is facilitated by patient registries, information technology, health information exchange or other means to track key activities to help ensure patients receive coordinated care when and where they need it.  

Care Coordination and the Interdisciplinary Care Team

BCBSIL will offer health care management services to MMAI, ICP, FHP and MLTSS members for effective coordination between providers and services across the full range of medical and social supports.  

MMAI, ICP, FHP and MLTSS members will be assigned a Care Coordinator to review their medical, behavioral health, social and long term service and support needs. The Care Coordinator will conduct a health screening assessment within 30 days after enrollment to determine each member’s risk level – Low, Moderate or High. Based on the member’s risk level, the Care Coordinator will develop an individualized Care Plan.  

In addition to developing a plan for care, the Care Coordinator is responsible for leading an Interdisciplinary Care Team, which may include, but is not limited to, a combination of the following:

  • Physicians (Primary Care Physicians and Specialists)
  • Behavioral health practitioners
  • Social workers
  • Counselors and clinicians experienced in advanced directives, care preferences and palliative care
  • Pharmacists
  • Community health workers
  • Community based support and beneficiary advocacy groups
  • Family members
  • Caregivers