Care Coordination at Clinix

In 2017, Clinix was accepted into a 5- year pilot program called Comprehensive Primary Care Plus (CPC+).  Medicare created this pilot to assist medical offices like ours to redesign our practices to better address the special needs of different patient populations. One of the hallmarks of this pilot is that it assists the practice in providing care management for high risk, high-need patients.  This could include the elderly, those patients recently hospitalized or patients newly diagnosed with a chronic disease (such as diabetes).

My name is Cindy Stillman and I am the Director of Operations and I have been a part of the Clinix team for over 27 years. My primary responsibility is to assist physicians and staff in caring for their patients in a complex and changing healthcare environment.  Our decision to participate in the Medicare pilot was largely influenced by my mother’s passing in September 2015.  I consider myself to be quite savvy regarding healthcare, but the last year of her life was frustrating and confusing, even for me.  Mom was able to live independently for 90 years with the loving support of her close family.  The last year of her life, however, was spent in either a hospital or a rehab facility, with the final 3 months in a memory care unit.  Although the staff at the memory care unit was wonderful as was the care she received, she nevertheless failed to thrive.  Her sudden memory loss, vulnerability and fear seemingly affected her willingness to eat or take her medications. 

We wished we could have found a way to keep her in the familiarity and comfort of her own home.  My mom had suddenly become one of those high-risk, high-need patients; my family and I could have used the support of a Care Coordination Team. 

Examples of Care Coordination Activities

  • Help transition a patient from the hospital setting to home after a hospital stay or surgery
  • Coordinate care for a patient with chronic conditions who sees multiple specialists by ensuring test results are accessible to all providers delivering care and navigating insurance coverage
  • Assist to obtain social supports like transportation and finding more affordable medications
  • Provide emotional support to the patient during difficult times such as job loss, death of a loved one and stressful times in general
  • Support the caregiver of the patient