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Integrated Care Coordination

West Virginia Senior Advantage Integrated Care Coordination Model

We specialize in providing a personalized, compassionate clinical care and services model for our West Virginia Senior Advantage (HMO SNP) Members.

Our model organizes best practices and industry innovations including:

  • A primary care physician (PCP) and advanced practice clinician (APC) care team provide onsite, nursing facility-based PCP support for each and every enrolled member.
  • A Health Risk Assessment Tool (HRAT) drives an Individualized Care Plan (ICP).
  • A care management platform that helps identify needed preventive health/HEDIS services, ensures the use of evidence based guidelines, and facilitates care team communications for integrated care coordination.
  • Frequent face-to-face member interactions that identify member care preferences and allow time for important care decision discussions and counseling.

Through close monitoring of our enrolled members, advanced practice clinicians can identify changes in members’ health conditions and quickly determine need for ongoing care.

Our Integrated Care Coordination Model produces comprehensive and coordinated care across medical, social, psychological, and pharmaceutical interventions to provide personalized care pathways.