Download Community Care of North Carolina

The Child Health Accountable Care
Collaborative (CHACC):
Strengthening the Bond Between the
Pediatric Subspecialist and the PatientCentered Medical Home
Mary Jones, RN, CHACC Coordinator
Disclosures
I have no conflicts of interest or financial disclosures
Goals
• Briefly describe Community Care of North Carolina
(CCNC) & Medicaid
• Describe the program goals for the Children’s Health
Accountable Care Collaborative
• Discuss the challenges of care for children with
chronic and complex diseases and the role of care
coordination
• Discuss the creation and use of specific treatment and
referral guidelines in the care of children with special
healthcare needs
Community Care of NC
 Statewide primary care medical home & care management system
 Rests on foundation of Carolina Access in which Medicaid patients
are linked to a primary care home
 Provides resources to improve access to, quality of and
coordination of care across the different segments of the local
health care system and decrease cost of care
 Private-public partnership (all savings stay in NC)
 Provides ready access to data
 Community based, locally driven, provider led
CCNC Goals
Evolving towards “Wellness” based case versus “Illness” based care.
Consolidation of hospitals, practices, and health care systems into
larger integrated systems (shared responsibility of care by physicians
and hospitals) is now the norm
Health care is evolving toward patient-centered using medical home
(a single site or home for coordination of a patient’s health care) as the
focus of the care structure
Technology allows access to and new approaches to data
What is a “Medical Home?”
 A medical home is defined as primary care that is
accessible, continuous, comprehensive, family centered,
coordinated, compassionate, and culturally effective.
(American Academy of Pediatrics)
 “My doctor is….”
6
Childhood Accountable Care
Collaborative
How it started..
 Started in 2013 as Federal CMMI Award for 2 years to improve care
for children with Medicaid & complex medical conditions ($9.3
million over 3 years)
 Statewide initiative involving local CCNC network primary care
homes, 5 academic medical centers, 7 tertiary hospitals, and
Pediatric Subspecialists- 7/2015 has been continued in local areas
by Community Care Plan of NC or Hospitals
Program Goals
 Engage primary care providers and pediatric subspecialists across the
state to share responsibility and accountability for pediatric primary,
subspecialty, and hospital care.
 Primary care providers and peds subspecialists jointly develop and
utilize evidence-based guidelines of care for pediatric chronic illnesses
and high volume referrals to peds subspecialists. Actively engage in comanagement of these children.
 Provide active care management to children under the care of pediatric
subspecialists through embedded care managers and patient
coordinators at tertiary hospitals and provide a warm hand-off to CCNC
network care managers.
 Reduce costs of care for this patient population (target is 2%)
Outcome Targets of Program
 Provide a model for medical home-medical center
collaboration in care of children with special health
care needs
 Develop statewide evidence based management
schemes for complex and chronic illnesses in
children
 Establish referral guidelines to streamline
consultation
 Reduce cost of care for children with special health
care needs
 Improved access to necessary pediatric subspecialty
care in a timely and efficient way
9
Who are the NC children with
Chronic or Complex illnesses and
what are the challenges in their
care?
Background
 FACT: 5% of Children under 18 incur 54% of
the cost for children’s care in Medicaid
Who are these children and what can be saved
on cost while maintaining or improving quality of
care?
11
Issues for Children with Chronic
and Complex Illness in NC
 Location of and Access to the subspecialists (long waits
for appointments-up to 4 months or more)
 Communication with PCPs and co-management
 Where is the Medical Home? Family confusion (My
doctor is….)
 Coordination of access to services
12
CHACC vs C5
 Who is a C5 patient? Medically complex, often
requiring technology (trach/vent), needing active care
coordination. C5 makes home visits and hosts
patients in a weekly referral clinic with link back to
primary care medical home
 Who is a CHACC patient? High cost, chronically ill
patient seen in a specialty clinic, needing care
coordination and link to primary care medical home;
often various social concerns
CHACC goals
 Provide continuity of care for patients who see our
subspecialists
 Enhance what is done in the primary care setting at
the time of referral before the patient sees the
subspecialist
 Improve communication with the family and the
medical home after the visit- CHACC Care plans
 Better meet the needs of the PCMHs and the
subspecialists
 Decrease unnecessary referrals and return visits to
subspecialists to reduce wait time for new referrals
CHACC goals cont.
 Reduce hospitalizations and ED visits
 Help with medication compliance and education
 Ensure community f/u in the home (HV in Pitt County)
Care Coordination & Case
Management
 CHACC embeds pediatric specialty care
managers in specialist clinics
 Develop the “CHACC Care Plan” to facilitate
collaboration between pediatric sub-specialists
and primary care physician
 Support families with Co-Management.
CHACC Care Plan
CHACC Care Plan pg2
CHACC Care Plan pg3
CHACC care plan pg4
Case Management at
Subspecialty Care location
 Case Manager Role: coordinate care and medical needs
of patients with CCNC case manager, subspecialty
providers, and PCP.
 Patient Advocate Role: provide assistance for family with
social needs, appts, and transportation; assist case
manager
21
Who are we?
 Our Vidant based Center for Children with Complex
and Chronic Conditions (C5): Medical directors from
BSOM (Drs Willson and Zepeda), A Nurse Practioner
(Clay Parker, NP), and 3 care coordinators (Kathy,
Tieranny,and Rhonda)
 Our CHACC program is supported through the
Community Care Plan of Eastern Carolina (CCPEC)
and Vidant Medical Center: Medical champion (Dr.
Willson), 2 care coordinators (Mary, Cierra), and 2
patient navigators (Michael, Davey Ann)
Co-Management Guidelines for Primary
Care Physicians and Subspecialists
 Develop CME for PCPs and Subspecialists about the
guidelines
 Track outcomes by ED and hospital utilization
 Repeat cycles with appropriate “expert panels” to cover
a series of diseases and disorders where comanagement is needed.
 Available now are guidelines for GERD management
Constipation, Sickle Cell, and Abdominal Pain
 http://www.communitycarenc.com/emerginginitiatives/child-health-accountable-carecollaborative/chacc-gi/
23
Co-Management Guidelines for Primary
Care Physicians and Subspecialists
 Joint development of co-management guidelines with
PCPs and Subspecialists
 Process: Evidence-based review of literature around the
subject and published guidelines for referral, pediatric
endocrinologists, obesity center directors, and PCPs
from CCNC invited to attend, discussion of the review,
development of consensus on management by PCP and
Subspecialists-web site initiated with NC Medicaid to
publish the guidelines
24
Referral Sources
 Pediatric Specialists
 Hospital
 NICU
 PICU
 Pediatric Floor
 Primary Care Providers
 CDSA
 CC4C
ECU Clinics Where CHACC
Patients Are Followed
 Nephrology
 Hematology
 Gastrointestinal
 Cardiac
 Healthy Weight
 Endocrine
 Physical Medicine &
Rehab
 Surgery
 Pulmonary
 Behavior/Develop.
 Infectious Disease
 Neurosurgery
 Neurology
 Adult Transition Clinic
CHACC Referral Sources
Referral Source
ECU Peds Nephro
Vidant-NICU
Vidant-SW
List-CHACC ADT
ECU Peds Specialty-SW
List-TCP 13
List-Vidant Hospital
CC4C CM
Quantity
%age
89
27
25
15
12
10
8
7
24.58%
9.32%
8.47%
8.47%
8.47%
5.93%
5.93%
5.93%
CCPEC CM
7
5.08%
List-ECU Peds Specialty
ECU Neurology
ECU Peds Endo
ECU Peds Cardiolgy
ECU APHC
ECU Peds Pulmonary
ECU Peds Surgery
C5
CHACC- Duke
CHACC- UNC
6
4
4
3
2
2
2
1
1
1
2.54%
2.54%
1.69%
1.69%
1.69%
0.85%
0.85%
0.85%
0.85%
0.85%
1
1
1
218
0.85%
0.85%
0.85%
100.00%
CHACC-CCWJC
Cumberland Hospital-VA
ECU Peds ID
Total
Specialist Referrals
ECU/Vidant CHACC Referral Source
100
90
89
80
70
60
Quantity 50
40
30
20
10
27
25
15
12
Quantity
10
8
7
7
6
4
4
Source
0
3
2
2
2
1
1
1
1
1
1
PCP Referrals
PCP
ECU Pediatrics
Eastern Carolina Pediatrics
Kinston Pediatrics
Goldsboro Pediatrics
ECU APHC
Washington Pediatrics
Boice Willis Clinic
Greenville Pediatric Services
Jacksonville Children's Clinic
MTW County Health Dept
Mt Olive Pediatrics
Benson Area Medical Center
Kinston Community Health Center
Vidant Chowan Pediatrics
Carolina East IM Pediatrics
Children's Health Services
Park Avenue Pediatrics
Halifax Pediatrics
Coastal Childrens Clinic
Craven County Health Dept
Vidant MultiSpecialty Clinic Tarboro
Goshen Medical Center
Vidant Chowan Family Practice
Kate B Reynolds
Our Childrens Clinic
ECU Family Medicine
ECU Firetower Clinic
Kinston Medical Specialist Pink Hill
Vidant Family Medicine Allen Street
Carolina Pediatrics
Eastern North Carolina Medical Group
KidsCare Pediatrics
Vidant Pediatrics Kenansville
Quantity
49
15
14
12
11
10
9
8
8
8
7
5
5
5
4
4
4
4
3
3
3
3
3
2
2
2
2
2
2
1
1
1
1
%age
21.19%
11.02%
7.63%
5.93%
5.93%
5.08%
5.08%
4.24%
3.39%
3.39%
2.54%
2.54%
2.54%
1.69%
1.69%
1.69%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
0.85%
PCP Referrals
ECU/Vidant CHACC Patient PCP Clinics
60
49
50
Quantity
40
30
20
15 14
10
12 11
10 9
8
8
8
7
5
5
5
4
4
4
4
3
3
0
0
Primary Care Physician Clinics
3
3
3
2
2
2
2
2
2
1
1
1
Quantity
CHACC/CCPEC CoManagement Process
Children with complex, chronic
Illnesses
CCNC Networks--Medical
Home/Primary Care Providers
CCNC Care Managers
CC4C Care Managers
Co-management
CHACC Care Manager
Patient Coordinators
Case Studies
 Patient A-Chronic kidney disease, abnormal GU
anatomy, recurrent UTIs, significant social
barriers
 Hospital visits 2014:14, then 2015:5
 CHACC involvement has been crucial in
coordination of patient’s care as family is hesitant
to work with new providers.
 CHACC assistance with medical supplies, appt
coordination, and compliance
Case Studies cont.
 Patient B-nephrotic syndrome, HTN, extreme
social barriers (language, compliance, literacy)
 Hospital visits increased due to condition over
time
 CHACC has arranged for medications delivered to
home, medication calendars in Spanish, home
visits set up with CCNC-all have increased
compliance and kept patient in remission for
longer bursts
Case Studies cont.
 Patient C-diabetes insipidus, Gtube, social
concerns
 Hospital visits 2013:3, to present-0
 CHACC has assisted with getting Gtube feeds
done at patient’s school and daycare; patient has
gained weight appropriately and labs have
normalized