June 13, 2017

Community-Based Health Intervention™


Community-Based Health Intervention™

  • National recognition for best practices of data-driven program management, highly effective data use and highly formalized accountability.
  • 99% of patient’s participating in the satisfaction survey reported that they feel satisfied with the intervention.
  • 67% of those responding to the survey said that they feel more confident about managing issues related to their health care.

One of 120+ nationwide teams contracted with CMS for the Community-Based Care Transitions Demonstration Project, the Southern Ohio Community Care Transitions Project (SOCCTP) was one of less than twenty that completed the five year demonstration project.  The SOCCTP team was comprised of five hospital partners and three Area Agencies on Aging covering 26 Ohio counties and a handful of counties in West Virginia and Kentucky.

The Southern Ohio Care Transitions Project successfully transitioned over 14,500 high risk patients with a successful readmission reduction rate for our participants of 30% preventing over 900 readmissions saving CMS over $10M.  Over the course of our five year project, we expanded our intervention to more than a “care transitional” model.

Social determinants of health are driving up health care costs anywhere from 60-80%.  If an individual cannot meet their basic needs for daily living they are not able to focus on their health care needs. Our project led the nation for best practices of data driven program management, highly effective data use and highly formalized accountability.

Using our experience and success from the CMS project, we set our sights on developing a standardized product, the Community-Based Health Intervention™ (CBHI™), which could be provided through the statewide network.

CBHI™ provides feedback to providers and payers in a timely manner facilitating effective communication and providing information previously unavailable to the healthcare provider.  CBHI™ is built into an interoperable HIPAA compliant high-performing data platform complete with electronic billing and referral capability, data analytics and reporting.  CBHI™ supports STAR, HEDIS, Health Outcomes Survey, Quality Improvement Activities related to the Medical Loss Ratio, and CAHPS.

If individuals cannot meet their basic needs for daily living, it becomes increasingly difficult for them to focus on their health care needs.
We can help.

The Community-Based Health Intervention™ provides:

  • Community-based visit by Licensed Nurse or Social Worker
  • Medication Inventory
  • Assessments for falls, depression, nutrition
  • Risk Stratification
  • Disease Specific Health Education
  • Social Determinants Review and Referrals
  • Advance Directives Education and State-approved forms
  • Weekly Touch point throughout 30-day intervention
  • Assurance of timely post-discharge follow-up with PCP when appropriate
  • Feedback to payers and providers
  • Supported by a HIPAA compliant, interoperable data platform

Learn More about CBHI™:
Fact Sheet

Contact Us at: 1-800-331-2644 option 4
or email: populationhealth@buckeyehills.org