Frequently Asked Questions

Patient Navigators main role is to become advocates for quality standards of care and the promotion of healthy lifestyles throughout patient engagement and care coordination.
  • Patient Engagement: assist patients in navigating the health care system and encourage preventive and chronic care management to ensure the highest level of care. Patient navigators will facilitate necessary follow-up appointments, preventive screenings, lab work, and medical imaging procedures.
  • Care Team coordination: support preventive and chronic care to foster strong patient-provider relationships. Works towards increasing patient adherence to their medical plan. And appropriately refers patients to health coach, social work, and community-based resources to facilitated health maintenance and self-management.

The Population Health Pharmacist serves as a resource for the entire CIN/ACO clinical healthcare team, working toward the overall goal of effectively managing the health and wellbeing of our population of attributed patients, with an emphasis on patients with chronic or complex diseases and/or high utilization patterns.

The Population Health Pharmacist is responsible for providing expert advice on the use of medications and on the provision of pharmacy services to medical providers and the clinical healthcare staff, including the Health Coaches.

Working at the programmatic level, the Population Health Pharmacist makes recommendations to the formulary of the CIN; works closely with the Medical Director of the CIN/ACO to advise on protocols and standards of practice related to medications and pharmacy services; and serves as a consultant to the clinical team to review medication schedules and assess for: appropriate use of medications to treat condition(s) based on clinical finding; polypharmacy; cost; and the potential for a simplified regimen.

The PHM Pharmacist serves as a liaison to other clinical services along the continuum of care, including support services.  In order to provide the best and safest pharmaceutical service and care to all patients in the CIN/ACO network, the Population Health Pharmacist provides care using the most current drug concepts and technologies available.

These Services May Include but are Not Limited to:

  • Dispensing medications
  • Participation in inter-professional care coordination rounds
  • Ensuring appropriate dosing of medications
  • Interpreting cultures
  • Therapeutic drug monitoring
  • Review of medication profiles
  • Conducting educational programs for providers/ patients
  • Providing drug information
  • Medication reconciliation
  • Training of new pharmacists
  • Active support of pharmacy residency and student programs

The LPN Care Coordinator role was developed to support the organization's increasing commitment to value-based and patient centered health care.  The LPN Care Coordinator will work with patients identified as at risk for avoidable ER and inpatient admissions within a 30-day cycle.  The LPN Care Coordinator will utilize predetermined patient lists and targeted interventions that may include education, coordination and consultation to help prevent ER and inpatient utilizations.

The LPN Care Coordinator also serves as liaison to other services along the continuum of care and community support services.

A Risk Adjustment Coding Auditor is an expert on current Medicare coding and billing requirements , ICD-10 and CMS regulations.  The coder conducts retrospective and prospective audits of HCC coding by means of pre-visit planning and post visit reviews in addition to:
  1. Performing coding quality audits and evaluating clinical documentation of provider charts to support CCD, HCC, Risk Adjustment and ensures the proper level of payment.
  2. Uses claims data provided by Edifecs/Health Fidelity reports, performs suspect condition identification and validation.
  3. Collects and analyzes data to formulate recommendations and solutions based on audit trends and results.
  4. Provides regular feedback to leadership on performance improvement opportunities as a result of performance gaps.
  5. Develops and participates in orientation and continuing education of providers, clinical staff and ambulatory coders.

The Mobile Integrated Services Team provides multidisciplinary primary care/oversights to patients in the home/community setting, including coordination with other healthcare providers and community services.

MIST provides multidisciplinary primary care/oversight to patients in the home/community setting, including coordination with other healthcare providers and community services. The team optimizes care by offering interdisciplinary coordination, behavioral care, and social supports as part of primary care within the home; rapid response to urgent and acute care needs; palliative care; and support for family members and caregivers. The MIST team consists of a : Manager ,Nurse Practitioner, RN Care Manager, Licensed Master Social Worker ( LMSW) and a Care Coordination Assistant. Patient Criteria for Consideration:
  • Resides in Onondaga County
  • Homebound/unable to access ambulatory care office for visits
  • Is attributed to St. Joseph's Health BPCI/ACO/ACQA
  • Must have a PCP or provider in the community who will collaborate with the MIST on an ongoing basis.