Care Coordination:Breaking It Down

Paul Kaye, MDVP for Practice Transformation

Hudson River HealthCareOctober 1, 2010

Improve the health of the population

Improve the experience of care

Reduce the cost

The Triple Aim

Population management Care management of the chronically ill Referral management (urgent and routine) Transitions coordination Reducing readmissions Coordinating care for special populations

What is Care Coordination?

Hudson River HealthCare Institute for Family Health Open Door Family Medical Centers CHCANYS Hudson Health Plan Taconic Health Information Network and

Community (THINC)

HUDSON INFORMATION TECHNOLOGY FOR COMMUNITY HEALTH

All 3 CHCs collaborated in achieving PCMH Level 3 recognition

Participants in THINC Medical Home project through Taconic IPA Medical Council

All 3 CHCs will participate in Johns Hopkins Guided Care curriculum

Joint commitment to useful information exchange with THINC RHIO

Setting the Stage

Aim: Provide 5000 diabetics with coordinated, continual, evidence-based care◦ Isn’t this the Triple Aim?

Measures in 3 domains:◦ Clinical Status (BP, A1C, LDL, screenings)◦ Care Coordination (SM goals, hospital follow-up,

admission and ER utilization rates)◦ Patient Experience (CAHPS or similar data)

HITCH HEAL 10 Project

Monthly Clinical Committee meeting drives technology requests

Multidisciplinary team includes MDs, CDEs, nursing, operations directors

Subcommittee of CDEs examining best practices and developing standard curriculum for all 3 CHC organizations

HITCH HEAL 10 Clinical Plan

Population management Care management of the chronically ill Referral management (urgent and routine) Transitions coordination Reducing readmissions Coordinating care for special populations

What is Care Coordination?

Agreement on diabetes clinical guidelines Embedded decision support Tracking of self management goals Tracking of regular screening (eye, foot, urine) Monitoring population to find new high risk

pts Systematic assessment of barriers to self

management and care Referral to community-based programs

(weight control, exercise, smoking)

Population Management

Use EHRs to identify pts with A1C >9 for intensive management◦ Monthly visit to PCP◦ Intensive monitoring with onsite testing◦ Individualized care plans recorded in EHR◦ Referral to standardized Diabetes Education

Program◦ Individual counseling as necessary◦ Referral to behavioral health as necessary◦ Multidisciplinary case conferencing

Care Management

CHW/patient navigators/Care Partners managing referrals from inception to reception of reports

Electronic communication between hospitals, specialists, and PCP

Referral to public benefit programs to cever costs of specialty care

Reinforce self management goals

Transitions Coordination

Focus on follow up of diabetic admissions Notification of admission and discharge Hospital discharge planners and CHC

coordinators communicate early Nursing phone call from CHC to discharged

pt within 24 hrs; daily phone followup as needed

Office visit with 2-5 days depending on status

Reducing Readmissions