OCH Services

Integrated Care Services

och evergreen walk-in clinic

Quality primary care is a foundation of the OCH mission. The OCH Integrated Care (ICare) department provides quality care to improve health conditions and lower healthcare costs for patients. Individualized care plans are developed with patients to meet quality measures including preventative care, screenings, referrals and follow ups. Our team utilizes Nurse Care Managers, Care Coordinators, Community Health Workers, Behavioral Health Consultants, and Chronic Care Mangers to provide support to the patient’s team of providers, nurses, and pharmacy.

ICare serves patients at all OCH locations throughout Missouri and Arkansas. Any patient (infant to geriatric) in the OCH system is eligible to receive age appropriate services, classes, resources, etc.

Director of Clinic Quality and Accreditation: Kristen Ogden

Clinic Executive Assistant/PCHH Co-Director: Dawn Eye

Incentive Program Director: Katie Mahoney

Resource Manager: Michelle Saffeels

CCM Coordinator: Jill Hewett

Quality Improvement Coordinator: Bethany Bright

Programs

Primary Care Health Home (PCHH)

OCH participates in a program called the Primary Care Health Home (PCHH) for its beneficiaries that have certain chronic diseases. It is designed to provide a higher level of quality care to improve health and lower healthcare costs. Individualized care plans are developed with the patients to meet quality measures including preventative care, screenings, referrals and follow-ups.

Chronic Care Management (CCM)

Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries outside of a regular doctor’s appointment, who have multiple (two or more) significant chronic conditions.

CCM services may include:

  • At least 20 minutes a month of CCM services
  • Personalized assistance from a dedicated health care professional who will work with you to create a care plan
  • Coordination of care between your pharmacy, specialists, testing centers, hospitals, and more
  • 24/7 emergency access to a health care professional
  • Expert assistance with setting and meeting your health goals

Patient Centered Medical Home (PCMH)

OCH takes pride in being a Patient Centered Medical Home (PCMH). Through medical home functions, we seek to improve the quality, effectiveness, and efficiency of the care we deliver while responding to each patient’s unique needs and preferences.

    Services

    Medicare/Medicaid Assistance

    OCH ICare has Certified Application Counselors (CAC) and Certified Medicare Counselors (CMC) available to help with a variety of insurance needs. Assistance and items can be given in person, or directly at a patient’s home. All services are free of charge (no clinic visit).

    • Medicaid and Medicare applications
    • Healthcare Marketplace Enrollment assistance
    • Sliding fee application

    Other application assistance

    • Housing application assistance
    • Food stamps application assistance
    • Low Income Home Energy Assistance Program (ILHEAP)
    • TANF – Temporary Assistance for Needy Families

    Counseling Assistance

    OCH ICare includes Licensed Clinical Social Workers (LCSW) who collaborates with the patient’s primary care provider. The ICare LCSWs can help with:

    • Domestic violence counseling
    • Counseling for stress management
    • Smoking cessation
    • Improving sleep habits
    • Develop goals to address life style dietary changes, improve physical activity treatment adherence, stress management, weight loss, tobacco cessation, and alcohol use reduction.
    • Assist with building support systems
    • After a patient has had a positive substance abuse screen
    • After a patient has had a positive depression screening

    All services are free of charge (no clinic visit). Additional services are available as well, call to verify!

    Resource options available for:

    • Housing and Homelessness
    • Food pantries
    • Transportation arrangements
    • Medical equipment
    • Appointment scheduling
    • Communication barriers
    • Pantry needs
    • MISC patient needs

    Additional services are available as well! If you are seeking assistance, give us a call! You may also email us at [email protected].

    Positions

    Nurse Care Manager (NCM)

    • Provides services to Medicaid beneficiaries
    • Foster direct relationships with patients and coordinate with primary care team, specialty care teams, and inpatient facilities.
    • Develop care plans that are patient driven
    • Serves as an additional resource & support person
    • Can answer health questions related to medications, diagnosis, lab results
    • Can provide health education
    • Help patients set and achieve health care goals
    • Can visit with you while at your appointment and/or follow up over the phone

    Behavioral Health Consultant (BHC)

    • Provide education and brief interventions to patients to address components of care plan (Examples: Medication routine, improving health habits, smoking cessation, improving sleep habits, and coping with stress)
    • Provide education about disease and depression screenings
    • Assist with medication adherence, treatment plan adherence, self-management support/goal setting.
    • Develop goals to address life style dietary changes, improve physical activity treatment adherence, stress management, weight loss, tobacco cessation, and alcohol use reduction.
    • Assist with building support systems

     

    Community Health Worker (CHW)

    • Provides resources and assistance with:
      • Appointment scheduling
      • Housing and Homelessness
      • Food pantries
      • Health Insurance and applications
      • Transportation arrangements
      • Communication barriers
      • Supportive advocates
      • Pantry needs
      • MISC patient needs

    Assistance can be provided in person or directly at a patient’s home. All services are free of charge (no clinic visit required). For resource assistance please email [email protected].

     

    Chronic Care Manager (CCM)

    • Provides services to Medicare beneficiaries outside of a regular doctor’s appointment
    • Works with patient’s Primary Care Provider (PCP)
    • Serves as an additional resource & support person
    • Can answer health questions related to medications, diagnosis, lab results
    • Can provide health education
    • Help patients set and achieve health care goals
    • Can visit with you while at your appointment and/or follow up over the phone