Member Spotlight – HUCU.ai

Coordinated Care Alliance Community-Based Patient-Centered Care with C-TAC Member Hucu.ai

C-TAC member organization Hucu.ai is empowering the Coordinated Care Alliance of Illinois (CCA) to provide seamless care transitions for hundreds of seriously ill patients in Illinois annually. Bailey Huffman, Executive Director provides leadership to teams of Community Based Care Coordinators in 24 Care Coordination Units across the state.  “The goal is to help older adults thrive at home and that means identifying barriers to health and social wellbeing and connecting services to meet those needs,” says Bailey.

CCA is using Hucu.ai to support the implementation of the Bridge Model of Transitional Care. Says Huffman, “Hucu is helping us improve the health and wellbeing of older adults. They not only provide us with the technology needed, but they are helping tackle the tough problems in the post-acute care space.”

Here’s how Hucu.ai is helping CCA to adhere to C-TAC’s Core Principles for Care:

1. Care is person and family-centered, improving quality of life. Hucu.ai enables CCA’s member organizations to communicate in person-centered channels and in Patient/Family Mode. This enables the coordination to be entirely person-centered.

2. Care is inclusive – reducing inequities and disparities and removing barriers to access and quality care. CCA’s primary mission is to coordinate care and remove any identified barriers to well-being for seniors. Hucu.ai helps free up time to focus on the challenges often faced by dual Medicaid and Medicare eligible patients, thus improving health equity.

3. Each person’s physical, social, psychological, and spiritual needs are assessed on an ongoing and standardized basis. The Bridge Model of Transitional Care explicitly calls on assessing and advocating for whole-person health and drawing on all community resources. Bridge Care Coordinators leverage chaplains, nutritional programs, transportation providers, home health organizations, and any other community resources that can help. Hucu makes that easy by keeping the whole team in the loop.

4. A care plan is developed, using shared decision-making, based on those needs and the person’s individual goals and preferences.
Hucu.ai provides a separate Patient/Family Mode to assure that feedback is continuous. This enables the CCA team to adapt to the changing needs of their clients in real-time while coordinating the professional team and informal support to meet those needs.

5. Care is provided by a qualified core interdisciplinary team, with additional team members as needed. CCA assures that an interdisciplinary team weighs in on complex patient needs and brings the right people to the table to honor each patient’s plans and wishes. Hucu.ai makes it easy to bring the right people to the right conversation at the right time.

6. Care is accessible 24/7 (using technology as appropriate) and available throughout the continuum of a serious illness (including in the home when appropriate). CCA can manage the full continuum of care with the support of easy-to-use technology that makes care coordinators more accessible to patients and their support systems. Hucu.ai supports this as well as the future potential to provide One Touch Telehealth integrated into the app.

7. Care is comprehensive, coordinated, with seamless transitions, and with the integration of clinical and community-based services and supports for the person and family caregiver(s). CCA manages patient journeys from hospital beds to the appropriate patient setting so that the patient can be as comfortable as possible. The care plan assures that all clinical and community-based input from the hospital to primary care is available and gaps in care are filled as quickly as possible. Hucu.ai supports this with easier communication.

8. Payment is value-based, available to qualified organizations of any size, includes risk adjustment, upfront investment, accountability, standardized metrics, and quality improvement, and covers both clinical and social services. Managed care is a growing part of the Medicare and Medicaid landscape in Illinois. CCA is activating managed care contracts by supporting Care Transitions from hospital to home. Hucu.ai is the tool that makes care coordination for value-based care successful.