Our Unique Model of Care

The goal for our medical, nursing and professional care teams at Central Ohio Primary Care Physicians is to work with every patient in the COPC Senior Care Advantage program to achieve their best health.

We have developed services for COPC Senior Care Advantage patients which will be helpful to you, bringing an even higher quality of care and attention to your health and for your wellbeing.

We have developed services for COPC Senior Care Advantage patients which will be helpful to you, bringing an even higher quality of care and attention to your health and for your wellbeing. Our unique model of care for COPC Senior Care Advantage patients begin with an annual wellness visit. The importance of this special visit can’t be underestimated. It allows you and your COPC physician to establish a comprehensive view of your health and establish a personalized prevention plan. You should think of this visit as the first step to identifying the services and healthy lifestyle and habits that are essential to improve and maintain your health and well-being throughout the year.


Overview of Our Annual Wellness Visit

  • Review and update of medical and family history


  • Measurement of your height, weight, BMI, blood pressure, and other medically necessary routine measurements that your COPC physician will determine


  • Development of a list of additional screenings that are recommended for you by your COPC physician.


  • Review of potential risk factors for depression


  • List of risk factors and conditions for which you are currently being treated and recommendations for other treatment options which may improve your health and quality of life.


  • Review of functional ability and your ability to perform basic tasks of daily living safely (cooking, cleaning, bathing, shopping).


  • Recommendations for participation in health education programs or specific disease management programs offered by COPC Senior Care Advantage


  • Health risk assessment that is monitored from year to year.


  • Updating and documenting a list of physician specialists and other providers currently treating you


All new members and recurring members are strongly recommended to schedule their annual wellness visit before the end of March each year. Call your physician to schedule your annual wellness visit today or at the latest by March of every year.


The COPC Senior Care Advantage program is very committed to the overall prevention services, screenings and quality measures that the U.S. Medicare program recommends for patients over 65 years of age. The COPC team believes addressing these measures is one of the hallmarks of high quality medical care for seniors.


All senior members of the COPC Senior Care Advantage program will be asked to work closely with their COPC physician in complying with these recommended guidelines. A few of the quality measures your COPC physician may discuss with you will include:


  • Controlling your blood pressure


  • Controlling your blood sugar if you are a diabetic


  • Steps you can take to reduce your chance of going back into the hospital again, if you have been recently hospitalized


In addition to your COPC primary care physician, you will be supported by members of the care team depending on your current or future health needs. They will help you, along with your doctor, to achieve your best health. We know that the aging process and state of health for seniors as they age can be very different from one person to another. Some of our patients will need more attention and care given their state of health than others. Usually younger seniors, who are in an excellent state of health, need comparatively less healthcare services from our team.


COPC RNs: Nurses at COPC play a vital role on the care team and in the health of their patients. You may work with a COPC RN to ensure you understand how to take your medications, for education and guidance on specific medical conditions or recommended care regimens, or medications or specialized care that is recommended upon discharge if you have been hospitalized.


COPC Care Coordinators: COPC Senior Care Advantage patients may be referred by their COPC primary care physician to COPC Care Coordinators. Care Coordinators work with your COPC primary care doctor to provide you extra support in the event that you need it due to illness or new medical condition. Our patients who are older or need extra assistance with newly diagnosed or complex medical conditions, or recent hospitalizations, concerns with balance, falls, multiple medications, or challenges with increased fatigue, memory loss or nutrition will benefit the most from these services.


Social Workers: COPC social workers help patients find support services for home health care, transportation, and activities of daily living, including shopping, food preparation, walking, bathing dressing, etc.


In addition to the COPC extended care team, comprehensive annual wellness visit and focus on national quality measures for Medicare patients, your COPC physician may recommend depending on your medical condition participation in special programs.

  • COPC Senior Care Advantage Chronic Obstructive Pulmonary Disease program


  • COPC Senior Care Advantage Innovative Diabetes Management program


  • COPC Senior Care Advantage Transitions of Care program


What is Care Management?


  • It is a program to identify and manage patients at high risk for complex, costly, or long-term health care needs.


  • Care management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes (CMSA, 2016).


  • Care Managers work with patients, families, and providers to assure medically appropriate integrated services are provided in a supportive cost-effective environment.


  • Care Managers follow patients throughout the continuum of care.


  • Care Managers assist with utilization of participating providers.


Care Management GOALS


  • Treat patients in the least restrictive setting.


  • Increase patient engagement to acquire knowledge, decision-making ability, and alteration in lifestyle to promote positive health outcomes.


  • Support the primary care physician (PCP)/Specialists by reinforcing the care treatment plan.


  • Avoid complications through early identification of problems, implementation of interventions, and development of patient-centric goals.


  • Promote effective utilization patterns


  • Foster communication between the primary care physician, specialists, and ancillary providers to integrate behavioral/medical services.


  • Encourage smoking cessation classes.


  • Reduce the total cost of care while improving outcomes.


  • Coordinate the services of social and public health agencies, when applicable.


Physician’s role

The PCP is responsible for coordinating all aspects of the patient’s health care needs; the case manager assists the PCP with the process.


PHYSICIANS SHOULD IDENTIFY…


  • Patients that are high risk for frequent hospitalizations


  • Inappropriate utilization of the ER


  • Non-adherence of treatment plan


  • Need for specialized care


  • Medically unstable or complex patients


  • Patients with special health care needs


  • Patients with drug seeking behavior


  • Patients with behavioral health needs


The Center for Medicare & Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA) support the evidence-based collaborative efforts between care management and the primary care physician to positively impact the health and well-being of our patients.


HOW TO MAKE A CARE MANAGEMENT REFERRAL


To request an assessment for Care Management, call (614) 259-0286 or send an email to care-management@copcadvantage.com.


Note: Please do not use this email for any medical or time sensitive issues. Do not include ANY personal identity information such as social security number, medical record number, or date of birth in the email.


Our chronic obstructive pulmonary disease (COPD) program is designed to help you:

  • Understand your COPD better


  • Take control over your health


  • Better recognize the signs and symptoms of your COPD


  • Make better health decisions


If you need this program, a care coordinator will call to help you schedule a visit with Becky Hoberty, COPC’s respiratory therapist. Becky has over 30 years of experience helping patients successfully manage symptoms of COPD. Becky Hoberty will help design a personalized plan to help you manage your symptoms, ensuring you are taking your medications correctly, using your inhaler, refilling your prescriptions and keeping your doctor appointments.


Becky offers COPC patients one-on-one assessments, which are 75-90 minutes in length, or support through monthly group meetings. These meetings may take place in your COPC physician’s office, or at one of COPC’s Same Day Centers in Columbus or Westerville.


For more information or to register for a COPD Management class, please call Becky at (614) 865-8041.

COPC Senior Care Advantage Innovative Diabetes Management program was developed to provide education and support for patients living with Adult Type 1 and Adult Type 2 diabetes. We’ll teach you the skills you need to manage your disease and reduce its potential long-term effects. There are now many effective treatments for diabetes, that greatly reduce the risks of often preventable and serious complications.


Unique to this program at COPC is that every member of the diabetes education team is also living well with diabetes, so we personally understand the challenges you face every day. When you join one of our classes, you will be joined by men and women like you who are looking for ways to enhance their health and well‐being through education. Not only will you learn more about living with diabetes, but you’ll enjoy being a part of it and gain confidence as you learn more, be more proactive in your treatment and start feeling your best.


Patients covered by the COPC Senior Care Advantage program are eligible to enroll in the Innovative Diabetes Management program, with a referral from a COPC primary care physician. Referred patients will receive a call from one of the program schedulers. They will discuss the program with you and what you need to do to fully participate and get the full benefit. These steps include:


Step 1 Getting Ready: Once you are recommended for the Innovative Diabetes Management program, you will receive a diabetes questionnaire. Please complete in advance and bring it with you to the first class. If you are not currently testing your blood sugar at home, you will need to learn how. We will offer glucose meter training at the first class. If you have any questions about obtaining a glucose meter please call us and we can help you at xxx.xxx.xxxx


Step 2 Attending Class: Upon enrollment, you will be asked to attend a series of 4 weekly classes, lasting two hours each. We encourage you to bring a family member or support person to class so they can learn too (at no charge).


The class topics include:

Class 1

Introduction to your health care team
Diabetes Myths
Behavior Change
Defined diet/food awareness
Identify carbohydrate
Label reading

Class 2

Self-­management strategies for diabetes control
Recognize your limits
Focus on your whole self, image and attitude
Food/meal planning
Medications (if needed)
Exercise
Checking your blood sugars at home
Keeping the scales balanced
Ways to make changes without upsetting the apple cart
Tools of the trade ??
Suggestions to assist you in managing your diabetes

Class 3

Tipping the scales
Low blood sugars
High blood sugars
Causes, symptoms, and treatment
Implications of the most current research
Avoidance of long term complications
Discuss causes and effects
How to plan and enjoy with diabetes
Community Resources

Class 4

Alcohol Eating out More on fat Stress reduction Special Topics
Sick day guidelines

After you have completed the classes, your doctor will receive a copy of your progress note describing your educational sessions.

Schedule a follow-­up appointment with your COPC physician for 3 months after completing classes. A hemoglobin A1C should be done at this time. Additional follow‐ups with us may be scheduled as needed to assist you in reaching your goals. Feel free to call us at (614) 447-9495 with any questions you might have.

Your care team at COPC Senior Care Advantage wants to be available whenever you need us and when you need us most. Informed by this philosophy we created our Transitions of Care program. We know how a stay in the hospital can make you anxious and at times, afraid. It is important to ensure that the care you receive in the hospital is well coordinated with the care your COPC primary care physician provides you in our office.


If you are hospitalized, a COPC nurse, known as a Transition of Care Specialist, is available to help you with your questions and concerns. These nurses will sit with you and introduce our COPC physicians, who are called hospitalists, who only provide care to our patients when they are in the hospital. Your Transition of Care Specialist will assist with coordinating the care you receive in the hospital informed by your personalized care plan you previously developed with your COCP primary care physician and reviewed at your annual wellness visit.


As part of the services provided by the Transition of Care Specialists, they will ensure your history, medications, and special needs known by your COPC primary care physician are also communicated to your treating hospitalist physician. The hospitalist will also stay in communication with your COPC physician and update them on information about your hospital stay and help transition back home by giving you discharge instructions when you leave the hospital.


After you leave the hospital, you will receive a call from your Transition of Care Specialist within 2-­‐3 days to see if you have questions regarding your discharge instructions or need help scheduling follow­‐up appointments or tests. This nurse will be available until you are comfortably back in the direct care of your COPC primary physician.