Meritus Health Care Transformation Organization (CTO)

What is a Care Transformation Organization (CTO)?

A CTO is an organization that hires, manages, and provides a diverse team of Care Management clinicians capable of providing an expansive array of care coordination to Maryland Primary Care Program (MDPCP) participating practices. It exists through the MDPCP program.

The Care Management team provided through The Meritus CTO works alongside and in collaboration with the primary care providers.

Below is a brief description of how each team member can help you and a general summary of the services they offer.

Registered Nurse (RN) Care Manager:

Our nurse care manager will work with you to help you manage chronic disease(s). Through either face-to-face meetings or phone calls, our nurses will provide you with the education, resources, care plans and ongoing support to help better control chronic disease(s). Our nurses can help obtain durable medical equipment, coordinate referrals, access home health, understand end-of-life issues and options, obtain transportation to appointments and more.

Social Worker:

Our social workers are experts in helping to identify and access community resources. They will evaluate your needs and make referrals as appropriate. Our social workers can connect patients, family and care givers with a variety of services that may help improve health and well-being. These include but are not limited to evaluating whether or not a patient qualifies for extra financial assistance, housing assistance, or access to transportation. Social workers can help patients and family members understand Medicare plans and connect the uninsured to insurance options. They serve a unique role in filling some of the gaps that affect care.

Diabetes Educator:

Diabetes is an increasingly common and serious disease that affects many people in our community. Managing diabetes can be quite overwhelming. Diabetes Educators meet with patients and family to discuss and address uncontrolled diabetes and assist with medications, Insulin, lifestyle factors, carbohydrate counting, glucose monitoring, Insulin pump therapy, and more. Our Diabetes Educator can work with patients, family, and providers to create an individual health care plan that works best for the individual beneficiary.

Respiratory Therapist:

Chronic respiratory diseases such as COPD and asthma affect many people and can significantly impact quality of life. Your Respiratory Therapist can help beneficiaries learn about their lung disease, explain how inhalers work and explain how best to manage the condition and avoid triggers. Services include disease-specific education, management options and tools, smoking cessation, spirometry, pulmonary medication reviews and more.

Behavioral Health Therapist:

Our Behavioral Health Therapists can provide one-to-one therapy sessions to address anxiety, depression, and other mental health issues that affect the quality of life. They can work with beneficiaries to determine coping strategies, identify and avoid triggers, and create an individual plan to help improve the quality of life. If additional mental health care is needed, our therapists are trained to facilitate referrals to the appropriate resources to meet beneficiary needs.

How do Primary Care Practices Partner with the Meritus CTO?

MDPCP practices are free to choose the CTO with which they partner, as long as the practice they select is within the established geographical territory associated with the CTO. The Meritus CTO geographic area includes all of Washington County Maryland (during PY2019).

What types of Assistance can The Meritus CTO Offer?

MDPCP practices are required by CMS to transform their care delivery processes and strive for Advanced Primary Care. CTOs assist the practice in this effort by providing services to practice beneficiaries that fall within the following categories:

  1. Care Coordination Services
  2. Support for Care Transitions
  3. Standardized Screening
  4. Data Tools and Informatics
  5. Practice Transformation Assistance