What is 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 individuals to function with maximum independence and self-sufficiency in their homes and communities as they choose.

The critical coordinating element 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, timely assessments and reassessments (at a minimum every 6 months; more often as warranted), 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, and the pharmacy formulary is customized to include specific medications.

Care coordination is part of care delivery, especially as it refers to coordinating and supporting the individual’s care and making sure there is a team leader for all of the person’s care needs.

Successful care coordination depends on four essential, fundamental components:

  • A service system that blends social supports and medical services, with the recognition that daily living needs are social; medical services are needed when illness or medical conditions threaten someone’s health.
  • A member-centered care and support team (involving family, clinicians, and caregivers identified by the member), based on the premise that each individual has unique needs and preferences, and should receive support they consider valuable to the extent possible.
  • A designated, responsive care coordinator with experience in working with persons with disabilities, who understands the need for rapid response in all matters, including any issues arising that could interfere with a person’s health, independence, or comfort.
  • Coordination of decision-making across all settings of care and support.