Download Agenda - Virtual Community for Collaborative Care

RCCO Delegated Care Management
Community Meeting
Thursday, November 19, 2015
10:00am-12:00pm
Agenda
10:00am
Welcome & Introductions
10:10am
GENERAL UPDATES – Jo English, Manager, Community
Based Care Coordination
10:15am
PRESENTATION: CO Access RCCO Care Management Team’s
Efforts on Transitions of Care and Use of CORHIO Data –
Beth Neuhalfen, Director, Practice Transformation
10:45am
REVIEW: Safe File Transfer Protocol (SFTP) Site - Jo
10:50am
CONVERSATION: Care Coordination Metrics Data – Jo and
Amy Akapo, Director, RCCO Operations
11:15am
CONVERSATION : Practice Performance Portfolio (P3)
Reports – Sheeba Ibidunni, PCMP Network Manager &
RCCO 5 Contract Manager
11:30am
Open Forum
12:00pm
Adjourn
GENERAL UPDATES – Jo English, Manager,
Community Based Care Coordination
Updated CO Access RCCO Team Contact List
Deliverables Document
Future Delegate Conversations:
Documentation Reviews
Stratification Processes
Data Collection and Reporting
PRESENTATION: CO Access RCCO Care Management
Team’s Efforts on Transitions of Care and Use of
CORHIO Data – Beth Neuhalfen, Director, Practice
Transformation
RCCO Team Structure
Manager, Care Management
Medicare – Medicaid
Program
Patient Navigator Team
RCCO Team Structure, Continued
Manager, Care Management
Community Health Worker Program
Supervisor, Special Populations
Supervisor, Transitions of Care
Prenatal
Refugee & Sickle Cell
Youth to Adulthood
HIV & LGBTQ
ED
Homeless & CJI
Inpatient
Chronic Conditions
SNF
CYSHCN
Regions 3 & 5-
Child & Youth with Special
Health Care Needs
Healthy Mom/Healthy Baby
• Maternity project
– Outreach 3 OB practices.
•
4C
– A collaboration between
• Tri-County Health Department
• Program for Children and Youth with
Special Health Care Needs
• Healthy Communities
•
Objective: Policy Change
– Priority #1: Increased coordination
of existing complex children
caseloads across the three
programs.
• Objective:
– To evaluate care management
effectiveness in maternity members to
satisfy State requirements and improve
key performance indicators.
– Objective data from a comparison year,
prior to the start of the program, will be
compared with objective data from the
pilot calendar year, in attempt to decrease
Key Performance Measures such as
prenatal care and screenings for
postpartum depression.
•
•
• Combined with CHP
– Priority #2: Clarify/establish roles
across care coordination programs.
CHP integration
– Asthma
– Diabetes/Obesity
Foster Children Pilot initiation
Sickle Cell
Refugee
• Evaluation of work with refugees
– Mixed Methods
•
•
•
•
Case Studies
Descriptives
Identification of baseline to measure
success
Outreach success
•
Sickle Cell Project
– A collaboration with Sickle Cell Clinic within
the Center for Cancer and Blood Disorders at
Children’s Hospital Colorado.
•
Objective
– Develop and evaluate a pilot project aiming to
improve:
• Treatment adherence
• Health outcomes
• Psychosocial functioning
•
Evaluation
– Mixed Methods
• Case Studies
• Descriptives
• Statistical Analysis
• “Time Line” Software
•
Publication in JAMA
– Timeline software will be utilized.
•
•
•
•
•
Visual data that demonstrates:
ER usage
Care manager interaction
Utilization of mental health
to show how care management has
impacted the population.
Timelines in Care Management
• Pilot Development
• Objective:
– To model a pilot after successful
Transitions Clinic Program for
transitioning ex-inmates and combine it
with Transitions of Care Model
measures.
•
•
•
(1) Increase ex-inmates with PCMP
(2) Increase ex-inmates with Medical
Homes in Colorado
(3) Decrease ER utilization in an effort to
provide patient centered care, improve
health and decrease costs related to
recidivism for the State.
• Homeless team
– Homeless and HIV & LGBTQ
– Homeless and Criminal Justice
– Homeless and Children and Families
• Evaluation
– Mixed Methods
•
•
•
•
Case Studies
Descriptives
Identification of baseline to measure
success
Outreach success
– Timeline software will be utilized.
•
•
•
•
•
Visual data that demonstrates:
ER usage
Care manager interaction
Utilization of mental health
to show how care management has
impacted the population.
All groups
• Evaluation of work with Chronic
Conditions
– Identify demographics of this population
– Mixed Methods
• Case Studies
• Descriptives
• Identification of baseline to measure
success
• Outreach success
– Timeline software will be utilized.
• Visual data that demonstrates:
• ER usage
• Care manager interaction
• Utilization of mental health
• to show how care management has
impacted the population.
•
Script for monitoring and evaluation reaching
completion
•
All groups are developing strategies for
measuring progress and outcomes.
What is a Care Transition?
• The term "care transitions" refers to the movement
patients make between health care practitioners and
settings as their condition and care needs change during
the course of a chronic or acute illness. For example, in the
course of an acute exacerbation of an illness, a patient
might receive care from a PCP or specialist in an outpatient
setting, then transition to a hospital physician and nursing
team during an inpatient admission before moving on to
yet another care team at a skilled nursing facility. Finally,
the patient might return home, where he or she would
receive care from a visiting nurse. Each of these shifts from
care providers and settings is defined as a care transition.
• https://www.youtube.com/watch?v=kqLIfSjsGA8#t=102
Leaving the Hospital or ED
Leaving the hospital can be a dangerous time for patients
• Why? Changes in care settings, care providers and
medications experienced after discharge can result in
errors that lead to health care complications. Many people
end up going back to the hospital because of these
complications, or because they were not prepared to
manage their own care.
• Unclear discharge instructions
• Conflicting instructions from different providers
• Medication errors, including dangerous drug interactions,
duplications
Transitions Team
• CORHIO (Colorado Regional Health Information
Organization) has been designated as the primary Health
Information Exchange (HIE) entity for the state of
Colorado. Colorado Access has built a connection to
CORHIO in order to receive Hospital data from various
facilities based on Colorado Access membership.
• Historically, Hospital data has been traded from Provider
to Provider. Colorado Access is the first payer to participate
in this arena and start receiving the hospital data.
Receiving this data will benefit us by allowing care
managers to see, (in Real Time) when a member has been
admitted or discharged to/from the hospital. This gives the
CM the ability to proactively plan for their ongoing care.
High
Inpatient
0-1 Week
Home Visit
• Medication Reconciliation
• PCMP follow up
• Patient Activation
• CTM 15
• HNA
• Confidence Tool
15-30 day
Call or Visit
• Confidence
Tool
• Action Plan
• Patient
Activation
60 day Call
• Confidence
Tool
• Action Plan
• Patient
Activation
90 day Call
•Confidence
Action Plan
•Patient
Activation
HIGH ED
HIGH
RISK/
LOW
RISK
HIGH RISK
LOW RISK
• <1 week Visit In
Home.
• Medication
reconciliation
• Confidence tool
action plan
• HNA
• PCMP Follow up
• CTM-3
• Patient Activation
• 1 week Call/Visit
• Medication reconciliation
• Confidence tool
• Action plan
• HNA
• PCMP Follow up
• CTM-3
• Patient Activation
30 day call or visit.
60 day call
Confidence tool
Action plan
Confidence
tool
Patient Activation
Action plan
Patient
Activation
30 day call
Confidence Tool,
Action Plan
Patient Activation
16
Helping More Transition
Unique Members Engaged by
Transitions Team
Growth Drivers
• Investing in Care
Management Staff
• Investing in Tools to
Identify Members in
Hospital
• On-site Care Management
Empowering Members
Transition Program Scripts
Medication
Reconciliation
Patient Activation
Action Plan
Health Assessments
Adults and Children
Comprehensive Health Assessments
Adults
21+
Children
(0-21)
Medical Home
Family Support
System
Community
Partners /
Resources
Medical/Behavioral
Providers
Member
Connecting the Medical Home
Community Partners / Resources
Family Support System
Medical Providers
Misc. Interaction Script Data
Interaction with and unique member count:
Interaction Script Data, continued
Interaction Script Data, continued
Pillars of Care
Medication Management
Demonstrates effective use of Medication Management System (medication organizer, flow chart, etc.)
For each medication, understands the purpose, when and how to take, and possible side effects
Demonstrates ability to accurately update medication list
Agrees to confirm medication list with PCP and/or Specialist
Red Flags
Demonstrates understanding of Red Flags, or warning signs that condition may be worsening
Reacts appropriately to Red Flags per education given (or understands how to react appropriately)
Medical Care Follow-up
Can schedule and follow through on appointment(s).
Writes a list of questions for PCP and/or specialist and brings to appointment
Personal Health Record
Understands the purpose of PHR and the importance of updating PHR
Agrees to bring PHR to every health encounter
25
Total Score & Unique Members
Total Score
Pillars of Care
Primary Required Activities of
Care Manager/Care Coordinator
29
•
Health Needs Assessment (HNA) – Comprehensive assessment of the whole person, strengths, needs, and
gaps in care
•
Care Plan/Action Plans – Comprehensive patient centered action plan with a systems of care influence
•
Transitions of Care – Coordination between systems of care, institution to home or community, between
providers, etc.
•
Medication Reconciliation – Comparison of medications ordered to medications the patient is taking
•
Coordination across all systems and providers
•
Medical self-management coaching, education and support
•
Attribution for those without a Primary Care Medical Provider (PCMP)
Member Transitions Story
30
Questions?
REVIEW: Safe File Transfer Protocol (SFTP) Site
Jo English, Manager, Community Based Care Coordination
SFTP Site Folders
CONVERSATION: RCCO Care Management Delegate Care
Coordination Metrics Comparison
Apr– Sept 2015
Jo English, Manager, Community Based Care Coordination and
Amy Akapo, Director, RCCO Operations
CONVERSATION: Practice Performance Portfolio (P3) Reports –
Sheeba Ibidunni, PCMP Network Manager & RCCO 5 Contract
Manager
P3 Conversation
• Recent KPI Calculation Changes
– 2014 ER Visit Baseline
• Review Current P3 Report
• Overview of Feedback Received
• Discuss Changes for the New Year
Open Forum
What questions, concerns or
considerations do you have?
Next Meeting
Thursday, January 21, 2016
LOCATION – TBD