AN EVOLVING SUCCESS STORY

THE INTEGRATION OF CARE COORDINATION:

Began 35+ years ago as an ‘Independent Practice Association’ (IPA) for Lane County physicians

Grew to become ‘Lane Independent Practice Association’ (LIPA) to provide management of the Medicaid State Health Plan, now with 58,000 members

Continued growth resulted in formation of ’Trillium Community Health Plan’; developed to serve the Medicare eligible members in Lane County; currently with 3,500 members

Added a small membership of 150 with the Healthy Kids program

Integrated Medical and Behavioral Health services January, 2012

Awarded CCO status by State in August, 2012 and combined all lines of business under Trillium Community Health Plan name

Trillium Community Health Plan (TCHP)

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20123 RN Care Coordinators & 3 Care Coordination Assistants working together to provide very high- level/high-touch care coordination services for:

3200 Medicare/Medicaid members 300 Medicare Advantage members

3 RN Exceptional-Needs Care Coordinators for:65,000 Medicaid members

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August 2012

The birth of the Trillium Coordinated Care

Organization

December 2012

Integration brings together physical healthcare coordination and behavioral healthcare coordination staff into a cohesive, functional team.

Integration of Community Health Workers into the Care Coordination Team begins.

Lane United CareConnect (LUCC) and Trillium Community Health Plan (TCHP) partnered together in providing additional care coordination services within the Trillium Coordinated Care Organization (CCO)

January 2013

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• Formerly, employees of Lane United CareConnect (LUCC); now employees of Trillium

• Dedicated people with a desire to help improve healthcare in Lane County

• Specially trained to provide a unique service to the Medicaid, Medicare, & dual-eligible members of our CCO community

Who are the Community Health Workers?

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Community Health Workers

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September 2013Changed our model of CC to multi-level care coordination teams working together with all Medicaid, Medicare, and Medicaid/Medicare members: RN Care Coordinators• Care Coordinators• Behavioral Health Care Coordinators• Medical Social Worker• Community Health Workers

• Development and deployment of community-wide consistency with THW education and scope of practice

• Metrics and evaluation of current CHW program

• Expansion of Perinatal Program to include greater integration of CHWs

• Involvement of CHWs with high-risk cardiac members

• Involvement of CHWs in Readmissions Program

• Integration of CHWs into ED transitions

So What’s Next ???

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Recently restructured Care Coordination Teams are now working together with their groups of specific Primary Care Clinics to:• Implement the movement of communication of

CC information to & from the Interdisciplinary Care Team (ICT) via our new web-based communication tool (CareTeamConnect).

• Proactively coordinate care based on member’s level of risk.

• Actively enroll identified members into special Care Programs for additional

Disease Management. • 11

The Trillium Care Coordination Team

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Coordination of Care for Positive Health Outcomes

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Trillium Member

PCP; Care Coordination; Other Providers; CHW

Social Services; Other Agencies

Trillium’s Definition of Coordination of Care:

Care Coordination is a community-wide team based approach to address the healthcare needs of the Trillium membership. Care Coordination incorporates physical health, behavioral health and community-based services, providers, and practitioners, to identify needs and ensure the provision of the right care at the right time, for our members.

What Is Care Coordination?

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Trillium Community Health Care Model

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Provider/TCHP identifies

patient with complex needs.

ExternalProvider makes

referral of patient to

Trillium Care Coordination.

• Trillium Care Coordination triages patient referral to determine if CHW is needed.• Trillium Care Coordination Team identified to work with CHW and patient

Trillium Care Coordination Team meets every 2 weeks with LUCC CHWs• Ongoing training• Complex Case Review• Updates on referred patients • Continued ongoing communication

LUCC receives triaged CHW referrals

• Care Plan issues for CHW assistance are identified on referral

Internal• Hot Spot List• Risk Stratification• Hospital

Readmissions• CC/UM Identification

referrals

Service Provider initiates a referral of their patient to the Trillium Care Coordination Team

External Referral Form

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Care Coordination Referral Date of Referral: _____________________________OHP/Medicare ID Number: __________________________ Patient’s Name: _________________________________________ DOB: _______________________________

Patient’s Phone #: _______________________ OK to leave message? Yes / No

Interpreter Needed? Yes / No If Yes, What Language is Needed? ________________________________ Patient’s Address: ______________________________________________________________________________ Patient’s Primary Care Medical Home/PCP:________________________________________________________

Identified Care Coordination needs (i.e. transportation, barriers to care, health literacy) Required: Please Fax Medication List, Problem List, Recent Chart Notes

1. 2. 3. Referral Initiated By: _______________________ ______________________ ________________________ Print Name Phone Fax Please Do Not Write Below This Line

Trillium Care Coordination Plan: (use second page, if indicated) 1. 2. 3. Completed By: _______________________ ________________________ ________________________ Print Name Phone Fax

Rev Draft: 7/1/13 - LW

Date of Referral

Trillium Review

Referral Source

Date to CHW program

Date CC issue resolved

Care Coordination Team: Name Phone/Email Trillium Community Health Worker Trillium RNCC Trillium Care Coordinator Behavioral Health Provider Senior and Disabled Services Other Care Team Member

Trillium Community Health Plan 1800 Mill Race Drive, Eugene OR 97403 Phone: 541-762-9031/ Fax: 541-434-1072

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Trillium Behavioral Health, Medical, and CHW Care Coordination Team Meeting

• Cardiac/Million Hearts• Tobacco Cessation in Pregnancy• Diabetes Disease Management• COPD/Asthma Disease Management• Pilot project-’Top 40’ Heart Failure

Disease Management• High-Risk IP Discharge • Restructure of Complex Case

Management into stand-alone teams

Special Care Programs

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Analytics SummaryGOAL METRIC QUESTION DATAImproved access to and experience of care 

Improved member self-perception of quality of care and health status

Satisfaction with program? SurveyImproved self-perceived health status? Member short-form assessment results

 

Care Coordination ensures access

Referrals to social service agencies and/or health education resources?

CTC: referrals by entity

Increased use of primary care and/or behavioral health services?

Claims: utilization per 1000

Improved health status and quality of care 

Improved member self-management of chronic conditions

Fewer hospital readmissions? Claims: utilization per 1000Decreased use of emergency room and urgent care services?

Claims: utilization per 1000

Fewer cancellations, missed appointments? Survey

Goals achieved? CTCImproved medication management and compliance with treatment regimens

Prescriptions filled? CTC and claims: Medications Prescribers

Lower costs long-term 

Program efficiency What are the characteristics of the members who use the program?

CTC and claims: members by demographics, condition,

risk factor Member willingness and ability to

engage  Are we reaching those most in need? CTC:

TAT from referral to acceptance/ denial TAT to first contact with CHW Smoking cessation rates

Program sustainability Which members are being served most efficiently with the best outcomes?

CTC: Members referred, offered, accepted Referral sources, by internal vs.

external Reasons not accepted Type, duration of contact Duration of program Calls and visits by CHW Goals achieved

What are the conditions best managed by the program?

CTC; Claims: Cost and utilization

Health care costs Did costs decrease or increase; for what types of services?

Claims: pre-and post; comparison with members not enrolled with CHW

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Trillium ‘All Care’ Care Coordination meetings

bring the entire team together to coordinate ALL care for the member:

• Physical Health CC• Behavioral Health CC• Community Health Workers• Utilization Review Nurses• Pharmacy• DME• ISNP CC

Next Steps…• Last month we held our 1st Community-wide

Care Coordination Meeting to introduce the Trillium CC Teams to their community counter-parts.

• We are hopeful through shared experiences to learn more about creating Community Care Coordination Meetings that are successful for all.

Questions?

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THANK YOU FOR YOUR TIME AND ATTENTION

Dr Holly Jo HodgesMedical Director, Trillium Community Health Plan541-431-1950

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