• admin
  • December 9, 2019

Federation has a long history of working collaboratively with managed care organizations, local governments, social service agencies, and other community-based organizations to develop truly innovative services that meet the needs of individuals who have traditionally been categorized as high-need utilizers. These services are individualized, creative, address core metrics, and most importantly, focus on meeting the individuals where they’re at.

Transition of Care

For many high-need individuals, discharge from a hospital can be a crucial time. Without the proper support, many do not follow- through with the discharge regimen and are prone to readmission. To support their health and reduce the number of avoidable hospital visits, Federation provides transition of care services to help support them in transitioning from one provider to another.

Transition of Care services focus on the first 30 days after discharge whereby a clinician will meet with an individual before they are discharged, and develop a plan to help connect them with needed services. This includes connecting them with their primary care provider as well as focusing on medication reconciliation, caregiver stress, self-education, adherence to appointments, social support and services, and their medical diagnosis.  The transition of care clinician plays a critical role by working to alleviate barriers to receiving car, helping to follow-up, providing much needed linkages to other supports and services.

Integration of Care

A growing aging population, healthcare reform, earlier diagnosis of disease states and an overall sicker population with more comorbidities than ever before has created the need for a more collaborative relationship between primary care and behavioral health care providers. For Federation, the role of the Physician Assistant has proven to be an invaluable asset which has allowed the agency to bridge the gap between primary care and behavioral health services.

Federation utilizes the services of the physician assistant (PA) across a majority of the programs we operate. The PA plays a unique role within the agency and serves as an intermediary between behavioral health providers and primary care doctors or specialists. The role bridges the gap between service providers breaking communication barriers and allowing clinicians to have a more comprehensive quality approach to the whole patient.  In addition, Federation has the technological capability to incorporate telehealth sessions as another way to make healthcare available and accessible to all.  As an agency, we are able to design a customized integrated service that will best meet the needs of the individuals we serve as well as the organizations and managed care providers we partner with.

The Peer Component

Federation has long recognized the unique ability of peers to engage with individuals on their journey to recovery by hope, support, and trust. Peers engage individuals on a personal level as they share their own experiences to help them take charge of their situation, re-establish hope, and provide proof that recovery is possible. Peers have knowledge of services and supports in the community such as, entitlements, housing, mental and medical health services as well as self-help resources. Peer specialists serve as living proof that recovery is possible.

As a pioneer of providing peer-based services since the mid 1980’s, Federation now incorporates the peer component into all services.  Overall, peers have shown great success in connecting individuals to needed services and reducing hospital re-admissions.  Our agency can design a service that best utilizes the peer component in a way that is optimal for your members.