THE DCP MODEL

THE DCP MODEL

The Disability Care Practice (DCP) model comprises patient-centered disability-competent care, and incorporates all services and supports covered by Medicare and Medicaid (including state waiver-card benefits). The model promotes integration of disability-competent care and services across all settings (hospitals, medical offices, residential), types of care and support (MDs, nurses, therapists, behavioral health), and community-based services, including informal (family) and formal (paid) caregivers, all with the goal of enabling people to function with maximum independence and self-sufficiency in their homes and communities as they choose.

 

The critical coordinating  component of the DCP model is the  interdisciplinary primary care/care coordination team that performs in-home comprehensive assessments, develops Individualized Care Plans (ICPs), and provides 24/7 continuity of clinical management with electronic health/medical record (“EMR”) support. The team is staffed for same-day/rapid response to new clinical problems in all settings and at all times: The primary care priorities include: comprehensive assessments, ICP development and monitoring, early intervention to prevent complications or exacerbations of chronic conditions, as well as continuity and clinical management of all transitions when hospitalization is necessary.  Behavioral health services are fully integrated with the primary care/care coordination team and an open-access specialty care network is maintained.  Decision-making about personal care and medical equipment allocation resides with the clinical team, at the point of care. Finally, the pharmacy formulary is customized to include specific medications.