The PCMH model of care includes key components such as: whole person focus on behavioral health and physical health; comprehensive focus on wellness, as well as acute and chronic conditions; increased access to care; improved quality of care; team-based approach to care management/coordination; and use of electronic health records (EHR) and health information technology to track and improve care.

Resources:

• Tobacco Cessation Counseling
• ICP
  • ICP Template (PDF)
  • Consent for Release of Sensitive Information - English (PDF)
  • Consent for Release of Sensitive Information - Spanish (PDF)
  • FAQs (PDF)
• Special Needs Unit Resource Guide

Social Determinants of Health

Social determinants of health (SDoH) are the conditions in the environment where people are born, grow, work, live and age. They include factors such as food security, housing stability, childcare needs, utility needs, economic stability, transportation needs, exposure to violence, and education needs. SDoH data offer rich insights into external conditions impacting health — an especially important consideration in underserved populations that may require complex care.

Recommended Best Practices

To inform continuous improvements to screening and follow-up processes, internally track the percentage of all adult and adolescent patients with at least one office or telemedicine visit who completed at least one SDoH assessment (i.e., G9919 or G9920) within the past year. Because patients may only complete some sections of the SDoH assessments, a “completed” screen can be defined as an assessment with at least one of the 2022 Domains answered/completed.

Social determinants of health (SDoH) are the conditions in the environment where people are born, grow, work, live and age. They include factors such as food security, housing stability, childcare needs, utility needs, economic stability, transportation needs, exposure to violence, and education needs. SDoH data offer rich insights into external conditions impacting health — an especially important consideration in underserved populations that may require complex care.

Resources:

• SDoH Resource Guide (PDF)
• Commonly Used SDoH Resources (PDF)
• View 2022 SDOH codes (PDF)

Special Needs Unit

Jefferson Health Plans’ Special Needs Unit (SNU) collaborates with providers to help your patients and our members get the healthcare services they need. Our SNU team can help arrange follow-up care after a hospital stay, coordinate outpatient and home care, connect patients to community-based social services and more.

Referrals can be sent via phone, email or fax.

• 215-548-4797
• Email ClinicalConnections@hpplans.com
• Fax form to 215-845-4181