RCCO Delegated Care Management Community Meeting

Thursday, November 19, 2015 10:00am-12:00pm

Agenda10:00am 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 ReviewsStratification ProcessesData 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

Supervisor, Special Populations

Prenatal Refugee & Sickle Cell

HIV & LGBTQHomeless & CJI

Chronic ConditionsCYSHCN

Supervisor, Transitions of Care

Youth to AdulthoodED

InpatientSNF

Community Health Worker Program

Regions 3 & 5-

• Maternity project– Outreach 3 OB practices.

• 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

• 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.

– Priority #2: Clarify/establish roles across care coordination programs.

• CHP integration – Asthma– Diabetes/Obesity

• Foster Children Pilot initiation

Healthy Mom/Healthy Baby

Child & Youth with Special Health Care Needs

• Evaluation of work with refugees– 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.

• 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

Refugee Sickle Cell

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

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HIGH ED HIGH RISK/ LOW RISK

HIGH RISK

• <1 week Visit In Home.

• Medication reconciliation

• Confidence tool action plan

• HNA• PCMP Follow up• CTM-3• Patient Activation

LOW RISK

• 1 week Call/Visit• Medication reconciliation• Confidence tool• Action plan• HNA• PCMP Follow up• CTM-3• Patient Activation

30 day call or visit. Confidence tool

Action plan Patient Activation

60 day callConfidence

toolAction plan

Patient Activation

30 day call Confidence Tool,

Action PlanPatient Activation

Helping More Transition

Growth Drivers• Investing in Care

Management Staff

• Investing in Tools to Identify Members in Hospital

• On-site Care Management

Unique Members Engaged by Transitions Team

Empowering Members

Transition Program Scripts Medication Reconciliation

Patient Activation

Action Plan

Health AssessmentsAdults and Children

Comprehensive Health Assessments

Adults21+

Children(0-21)

Medical Home

Member

Medical/Behavioral Providers

Family Support System

Community Partners / Resources

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 CareMedication 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

• 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)29

Member Transitions Story

30

Questions?

REVIEW: Safe File Transfer Protocol (SFTP) SiteJo 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