The Connect CARRE Program
The Connect CARRE Program is a Care Management and Wellness Program by the Center for
Adult Health, Department of Human Services, Division of Health Care Quality, Financing and
Purchasing, State of Rhode Island. For further information regarding this program, please
contact us at (401) 462-6311.
Connect CARRE is a comprehensive program designed for consumers with declining health and
frequent illnesses. Connect CARRE will:
Link consumers to a medical home with a team of providers and care coordinators including a Lead Physician, usually the Primary Care Physician, and a Nurse Care Manager (NCM),
Assist consumers in developing more consistent and supportive relationships with their health care providers,
Assist consumers and their families with managing chronic illness through educational programs, and
Identify and coordinate services and care in the community setting to assist consumers in maintaining wellness and reducing recurrent illness.
Program Overview
Utilizes lead physician and nurse care manager as core team members to coordinate individual’s care
Partners with community-based entity with care management model
Includes disease management principles to support MD practice
Includes health outcomes as program measures
Provides Enhanced Benefits
Builds linkages among medical care providers, behavioral health services, and community support services
Consumer focused / establishes a consumer advisory committee
Based upon initial consumer needs assessment, a care conference with the clinical team (including the Nurse Care Manager, Assistant Medical Director, Pharmacist and Social Worker) will be held to develop a care plan
Care management / care along the continuum coordinated by Nurse Care Manager
Program Goals and Objectives
The Connect CARRE program will benefit participating clients, physicians and the Medicaid Program.
Benefits to Participating Client:
Improve wellness of the participants
Maintain or improve functional status of the participants
Ensure a medical home for each participant
Increase participants' satisfaction with the health care system
Increase the ability of participants to manage their care
Decrease preventable hospitalizations and emergency department usage
Identify gaps in current delivery system for the target population and develop needed delivery system capacityBenefits to Participating Physicians:
Allow physicians to concentrate on medical care
Notify physician when patient is hospitalized or transferred to another setting
Reduce “no shows”
Facilitate referrals to community resources
Coordinate communications among consumers, providers and family
Provide a resource for benefit and coverage questions
May bring patients to practiceBenefits to Medicaid Program:
Assist the Medicaid Program in providing high quality, coordinated cost-effective medical care to Medicaid members without risking under service to the consumer
Assist the Medicaid Program in providing non-medical support services to Medicaid members to support health maintenance and slow the decline in health status
Target Population
In the first phase of the program, enrollment will be limited to:
Disabled and chronically ill Medicaid members age 22 and older
Between 150 to 200 Medicaid members with Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Diseases (COPD), Sickle Cell Anemia, Asthma, Diabetes, and Depression
Medicaid members at risk for recurrent adverse medical events
Medicaid members at risk for frequent hospitalizations and emergency room visits
Medicaid members who are frequent users of acute care services
Medicaid members residing in a community setting but lacking social and community supports
The following are exclusion criteria for the first phase of the program:
Not in MRDD Waiver
Not in a long-term care facility (nursing home or Eleanor Slater)
Not enrolled in Rite Care
NOTE: In the future, the program developed for this first phase population will be replicated for other populations.
Outcome Measures
Decrease in adverse medical events for program members
Improved health status of program members
Appropriate utilization of acute hospitalizations
Improved utilization of medical appointments
Improved appropriate medication compliance
Consumer Satisfaction
Physician Satisfaction
Disease Specific Clinical Outcome Measures
