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Proposal to Fund a Pilot Care Coordination Program for PPP Diabetic Patients:
For Discussion Purposes Only
March 15, 2005
Background on Care Coordination
Care coordination programs, also referred to as care management programs, are an important
component of broad quality improvement strategies. While the programs are diverse, they share
a common goal – identify and engage patients with chronic illness or high cost conditions who
will benefit from improved self-management and evidence-based treatment. Successful
initiatives have been shown to improve patients’ health status and reduce risk of hospitalization.
To be cost-effective, however, these programs need to be directed at the right patients.
Care coordination programs apply systems, science, incentives, and information to improve
medical practice and help patients manage medical conditions more effectively. Programs may
interact with an entire category of patients, such as diabetics, or specific subsets of high-risk
individuals. The common components of care coordination are:
 Population identification processes;
 Evidence-based practice guidelines;
 Collaborative practice models;
 Patient self-management;
 Process and outcome measurement; and
 Routine reporting/feedback involving patients, physicians, plan and care team.
Care Coordination is a central element of the Countywide Disease Management Program (DMP)
and “is critical to ensuring the implementation of a patient-focused care plan and open
communication with principal care providers.” Care coordination is performed by nurse
practitioners and nursing care specialists, and includes referral to appropriate ancillary resources
and services to meet patient’s ongoing identified needs and avoid unnecessary duplication of
services, and the use of innovative use of technology, including point-of-care reminders and
prompts which assist in real time decision support.
Proposal to Implement Pilot Project for Diabetic PPP Patients
Subsidize care coordination costs for a specified population of diabetic PPP patients. Under this
proposal, participating agencies would receive a quarterly lump-sum payment for coordinating
the care of a specified number of diabetic patients enrolled in a pilot diabetes care management
program. In exchange for payment, agencies would be required to submit information
confirming that each diabetic patient being paid for by the PPP program:

is a good candidate for care management, i.e. patient must be meet certain criteria for
participation (to be defined);

has been assigned a named nurse care manager; and

has received certain care management services (to be defined).
Agencies receiving funds for care management purposes would also be required to report on
specified outcome and process measures (to be determined).
COUNTY OF LOS ANGELES – DEPT OF HEALTH SERVICES – OFFICE OF AMBULATORY CARE
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DRAFT – FOR WORKGROUP PURPOSES ONLY – DO NOT CIRCULATE
Rationale
Because of limited and insufficient PPP program dollars, the County cannot realistically
reimbursement partner agencies for 100% of the cost of providing comprehensive diabetes
management services to all diabetic patients in the program without significantly reducing access
to care for other PPP patients. This proposal provides limited, but flexible, funding support to
help agencies further develop and sustain their care management services – an important
component of any successful diabetes management program.
This proposal also scores high on many of the PPP redesign criteria, agreed upon by the
Leadership Group.
REDESIGN CRITERIA
Maximizes Access to Care
PROJECTED OUTCOME FROM IMPLEMENTING THE
PROPOSED DIABETES MANAGEMENT PROGRAM
No Change: Maintains access to care for current PPP patients.
Recognizes differences in
patient cost and health care
needs
Encourages an appropriate
level of care
Modest improvement: Recognizes that many patients with
diabetes require greater resources to provide and coordinate care.
Maximizes the use of available
funding for the uninsured
No change: No other public funding sources are available for
coordinating the care of diabetic patients.
Encourages quality care
management
Significant improvement: The proposed pilot program provides
financial support for care coordination – the glue behind any
successful disease management program; assigning each patient a
care manager will allow for better lines of communication between
the patient and care provider.
Politically viable
Improvement: This is an incremental step forward that does not
consume a large amount of program resources; the proposed pilot
program is aligned with the goals of the Countywide Disease
Management Program and the disease management activities
already being performed by PPP agencies through the California
Quality Improvement Collaborative.
Adaptable
Improvement: Data collected on resource utilization and
outcomes will be useful in evaluating the benefits of the program;
data can be used to make programmatic improvements, to expand
the program, or to eliminate it if it has not proven to be successful.
Modest improvement: Reporting of certain process and outcome
measures promotes the use of acceptable standards of care for
diabetes patients.
COUNTY OF LOS ANGELES – DEPT OF HEALTH SERVICES – OFFICE OF AMBULATORY CARE
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