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Best Practices in Care CoordinationBest Practices in Care Coordination
Edward L. Schor, MD,Lucile Packard Foundation for Children’s Health
CCS Plus Care Coordination SummitCCS Plus Care Coordination SummitJune 8, 2012
1
Triple Aim Goals and Some ApproachesTriple Aim Goals and Some Approaches
• Improving the experience of careImproving the experience of care– Care planning and implementation– Receipt of recommended servicesp– Informed decision‐making
• Improving the health of populationsImproving the health of populations– Life course perspective– Prevention and health promotionp
• Reducing per capita costs of health care– Appropriate use of servicesAppropriate use of services– Efficient systems of care
2
What is Care Coordination?What is Care Coordination?
“Care coordination occurs when care plans are pimplemented by a variety of service providers and programs in an organized fashion.” – AAP
il hild i h i bili iCouncil on Children with Disabilities
“Pediatric care coordination is a patient andPediatric care coordination is a patient and family‐centered, assessment‐driven, team‐based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families.” – Antonelli, McAllister & P
3
Popp
Essential Elements of Quality Comprehensive Care CoordinationComprehensive Care Coordination
• Accessible, including community‐based• Qualified care coordinator• Intake screening• Comprehensive assessment• Comprehensive assessment• Develop a care or service plan• Family/patient‐centered goal setting, planning and servicesFamily/patient centered goal setting, planning and services• Services: Inform, arrange and/or provide services (includes
advocacy and financing)T i / f i f i i id• Transmit/transfer information among service providers
• Monitor service delivery• Ongoing reassessmentOngoing reassessment• Ongoing relationship between client and care coordinator (ideal)
4
Delivering Care CoordinationDelivering Care Coordination
Assessment
Goal SettingContinuous Monitoring
Goal Setting& Improvement
Care Planning and Facilitation
5Modified from: Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System. The Commonwealth Fund. May 2009
Distribution of Children By Chronic Illness C tCategory
Population Cost
0.06% 2.36%
M t t ti0.01% 0.64%
0 10% 1 68%Life Long Progressive
Metastatic Malignancy
0.10% 1.68%
2.45% 12.65%Life Long Progressive
Technology Dependent
5% 65%
12.30% 26.44%Episodic Chronic
Life Long Chronic
85.1% 56.2%Non‐Chronic
Source: J. Neff, Treo‐CRG 6
Care Coordination in Pediatric PracticesCare Coordination in Pediatric Practices
Keep List ofDesignated Care Keep List of Community Service
Providers57%
Designated Care Coordinator
81%39%
16%16%
Yes NoYes No
Commonwealth Fund IHP Survey 2009
Pediatric Practice Creates Written C Pl f CYSHCNCare Plans for CYSHCN
45%
33%
45%
33%
17%
3%
Often Sometimes Rarely NeverOften Sometimes Rarely Never
The Commonwealth Fund, IHP Survey, 2009 8
Pediatric Practices Receiving Payment for C C di tiCare Coordination
86%86%
9%1%
9%
All Payers Some Payers None
The Commonwealth Fund, IHP Survey, 2009 9
Care Coordination in Pediatric Primary Care P tiPractices
No Psychosocial Issues Psychosocial Issues*
Non‐CSHCN 9.4 minutes(clinical and referral
t d
14.1 minutes(mental health, legal and
i l i )management and education)
social services)
CSHCN 17.6 minutes 19.3 minutes(mental health legal and(mental health, legal, and social services)
Costs ranged from $4 39 to $12 86 per CC encounter; average $7 78Costs ranged from $4.39 to $12.86 per CC encounter; average $7.78
Source: Antonelli RC, Stille CJ, Antonelli DM. Care Coordination for CYSHCN. Pediatrics 2008; 122(1):e209‐e216
10
Improving Linkage: 3 Levels of StrategiesImproving Linkage: 3 Levels of Strategies
1. Practice‐level systems change
2. Community partnerships
h3. Community systems change
11Source: Fine & Mayer. Beyond Referral. The Commonwealth Fund, December 2006
Organizational Options for Care CoordinationOrganizational Options for Care CoordinationKey question: Point of Entry & Point of Service: Single Vs Multiple?
• Referral coordinator in practice or agency• Care Coordinator in practice or agency
Offi b d d b i l i• Office‐based supported by regional entity• Care coordinator shared among practices or agencies
Private arrangement– Private arrangement– Health care organization – Public agency
• Regional resource providing facilitation and support– Telehealth models: Help Me Grow; Massachusetts Child
Psychiatry Access ProjectPsychiatry Access Project– eReferral models: SF General; Doc2Doc
12
Mechanisms for Providing Care CoordinationMechanisms for Providing Care Coordination
• Individual care coordinator• Care coordination team• Face‐to‐face with client
C t t ith h i i (f t f th )• Contact with physician (face‐to‐face or other)• Various e‐care options:
– TelephoneTelephone– Email– Messaging devices– Digital photos– Video
• Relationship‐based among providers and organizations
13
Local Policies to Facilitate Care CoordinationLocal Policies to Facilitate Care Coordination
R f l d F db k S t• Referral and Feedback Systems
• Interagency AgreementsInteragency Agreements
– Accountability
– Standardized forms and processes
– Privacy policies (HIPAA FERPA IDEA)Privacy policies (HIPAA, FERPA, IDEA)
• Data Sharing Agreements
14
Structural Factors that Support High Quality Care CoordinationQuality Care Coordination
• Interdisciplinary advisory committeeInterdisciplinary advisory committee
• Parent advisory committee to practices
• Ongoing quality improvementOngoing quality improvement
• Adequate reimbursement
• Incentives for quality• Incentives for quality
• Clear standards and quality measures
H l h I f i h l• Health Information technology
• Interagency collaboration in community or state
15
Shared Resources: OutsourcingShared Resources: Outsourcing
PrimaryCare Primary
CareCC CC CareCC
CC
CC
PrimaryCare
16
Community Care of North Carolina: MedicaidCarolina: Medicaid
Asthma Initiative: Pediatric Asthma Hospitalization rates
(April 2000 – December 2002) • 14 networks, > 3,200 MDs, >800,000 patients( p )
In patient admission rate per 1000 member months
14 networks, 3,200 MDs, 800,000 patients
• $3 PMPM to each network
• Hire case managers/medical management staff
• $2.50 PMPM to each PCP to serve as medical home and
789
$2.50 PMPM to each PCP to serve as medical home and participate in disease management
• Care improvement: asthma, diabetes, screening/referral of young children for developmental problems, and more!
3456
more!
• Case management: identify and facilitate management of costly patients
• Cost savings analysis (per Mercer):
012
Access I Access II & III
– FY2003: $60 million– FY2004: $124 million– FY2005: $77‐85 million– FY2006: $154‐170 million
17Source: L. Allen Dobson, MD, presentation to ERISA Industry Committee, Washington, DC, March 12, 2007
FY2006: $154 170 million
Vermont Blueprint for Health Sharing Resources to Integrate CareSharing Resources to Integrate Care
& Control Costs
Hospitals
Community Care Team
CommunityPractice
CommunityP iCommunity Care Team
Nurse CoordinatorSocial Workers
DieticiansCommunity Health Workers
Mental Health & Substance Use Disorders
Practice
CommunityPracticeCommunity Health Workers
Care CoordinatorsPublic Health Prevention Specialist
Public Health
Practice
CommunityPracticePractice
18HIT Global Information Evaluation Operations
Cost SavingsCost Savings
• Adult practices with high proportion of chronicallyAdult practices with high proportion of chronicallyill patients are able to save money
• Direct interaction with the physicians and significant in‐person interaction with patients increased possibility of cost savings
• Pediatric practices with low proportion of chronically ill patients have not documented cost savings
19
Paying for Case Management and Care dCoordination
• Targeted Case Management• Targeted Case Management
• CPT Codes for Multi‐Disciplinary Care Coordination
• Capitated Payment: Per Member Per Month Fees
– Risk adjusted (biologic and social)
– Tiered based on complexity and time
• Pay for Performancey
• Medical Homes Certification Bonuses
• Health Homes enhanced federal matchHealth Homes enhanced federal match
20
Evaluating Care CoordinationEvaluating Care Coordination
Access Quality Cost
Structure
Process
Outcome
21
Centrality of FamiliesCentrality of Families
“The health and well‐being of children are
inextricably linked to their parents’ physical,
emotional and social health socialemotional and social health, social
circumstances, and child‐rearing practices.”
22Source: AAP Task Force on the Family. Family Pediatrics. Pediatrics, June 2003
ResourcesResources• Antonelli RC, McAllister JW, Popp J. Making Care Coordination A Critical Component of the
Pediatric Health System: A Multidisciplinary Framework. The Commonwealth Fund. May 2009. (www.cmwf.org)
• Fine A, Mayer R. Beyond Referral: Pediatric Care Linkages to Improve Developmental Health. The Commonwealth Fund. December 2006. (www.cmwf.org)
• Henderson M, Kaye N. Policies for Care Coordination Across Systems: Lessons from ABCD III. N ti l A d f St t H lth P li M 2012 ( h )National Academy for State Health Policy. May, 2012. (www.nashp.org)
• O’Malley AS, Tynan A, Cohen GR, Kemper N, Davis MM. Coordination of Care by Primary Care Practices: Strategies, Lessons and Implications. Center for Studying Health System Change. Research Brief No. 12, April, 2009
• Reducing Care Fragmentation: A Toolkit for Coordinating Care. The MacColl Center for Health Care Innovation at the Group Health Research Institute, Seattle Washington. http://www.improvingchroniccare.org/index.php?p=Care_Coordination&s=326
• Rosenbaum S Johnson K Jones E and Markus A Medicaid and Case Management to PromoteRosenbaum S, Johnson K, Jones E and Markus A. Medicaid and Case Management to Promote Health Child Development. George Washington University School of Public Health and Health Services for The Commonwealth Fund, 2009
http://www.gwumc.edu/sphhs/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_FB044708‐5056‐9D20‐3D1C4A53DFA85EC7.pdf
• Wise PH, Huffman LC, Brat G. A Critical Analysis of Care Coordination Strategies for Children with Special Health Care Needs. AHRQ Publication No. 07‐0054, June 2007
23