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<ul><li>NC Department of Health & Human Services </li></ul><ul><li>Division of Medical Assistance </li></ul><ul><li>Office...
North Carolina’s Strategy: <ul><li>Statewide primary care case management </li></ul><ul><li>Form community networks across...
Statewide Primary Care Case Management <ul><li>Carolina ACCESS started in 1991 </li></ul><ul><li>> 750,000 Medicaid patien...
Community Care of North Carolina <ul><li>Started in 1998 </li></ul><ul><li>Joins other community providers (hospitals, hea...
Community Care of North Carolina <ul><li>Focuses on improved quality, utilization and cost effectiveness </li></ul><ul><li...
Community Care of North Carolina AccessCare Network Sites AccessCare Network Counties Access II Care of Western NC Access ...
Community Care Networks:  <ul><li>Non-profit organizations </li></ul><ul><li>Comprised of safety net providers </li></ul><...
What Networks Do <ul><li>Assume responsibility for Medicaid recipients </li></ul><ul><li>Identify costly patients and cost...
Implementing Disease Management <ul><li>Evidence-based guidelines </li></ul><ul><li>Clinical directors set performance sta...
Managing High Risk Patients <ul><li>Identify high cost through claims analysis </li></ul><ul><li>Identify high risk throug...
Managing High-Cost Services: <ul><li>Pharmacy </li></ul><ul><li>—  Nursing home polypharmacy </li></ul><ul><li>—  Prescrip...
Building Accountability <ul><li>Chart audits </li></ul><ul><li>Practice profiles </li></ul><ul><li>Care management reports...
Current Initiatives <ul><li>Asthma </li></ul><ul><li>Diabetes </li></ul><ul><li>High cost services </li></ul><ul><ul><li>E...
Asthma Initiative <ul><li>First program initiative – began Jan. 1999  </li></ul><ul><li>Adopted best practice guidelines (...
Asthma Initiative Key Process Measures No. with asthma who had documentation of staging No. staged II – IV on inhaled cort...
Diabetes Initiative <ul><li>Second program-wide initiative – began July 2000 </li></ul><ul><li>Adopted best practice guide...
Diabetes Initiative ACCESS II-III  Diabetes Chart Audit Results Baseline (July – Dec. ’00) July – Dec. ‘01 July – Dec. ‘02
Community Care of NC creates an infrastructure for: <ul><li>Statewide Initiatives </li></ul><ul><li>Collaboration w/other ...
Lessons Learned <ul><li>Local buy-in a must </li></ul><ul><li>All stakeholders must be at the table </li></ul><ul><li>Ince...
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Transcript of "Community Care of North Carolina PowerPoint presentation"

  1. 1. <ul><li>NC Department of Health & Human Services </li></ul><ul><li>Division of Medical Assistance </li></ul><ul><li>Office of Research, Demonstrations & Rural Health </li></ul>HOME NEXT LAST
  2. 2. North Carolina’s Strategy: <ul><li>Statewide primary care case management </li></ul><ul><li>Form community networks across the state </li></ul><ul><li>Implement quality improvement initiatives through community networks </li></ul><ul><li>Cost containment initiatives </li></ul>HOME NEXT LAST
  3. 3. Statewide Primary Care Case Management <ul><li>Carolina ACCESS started in 1991 </li></ul><ul><li>> 750,000 Medicaid patients enrolled </li></ul><ul><li>> 4,000 PCPs participating </li></ul><ul><li>PCPs provide after hours and specialty referrals </li></ul>HOME NEXT LAST
  4. 4. Community Care of North Carolina <ul><li>Started in 1998 </li></ul><ul><li>Joins other community providers (hospitals, health departments and departments of social services) with physicians </li></ul><ul><li>Creates community networks that assume responsibility for managing Medicaid patient’s care </li></ul>Builds on Carolina ACCESS HOME NEXT LAST
  5. 5. Community Care of North Carolina <ul><li>Focuses on improved quality, utilization and cost effectiveness </li></ul><ul><li>13 Networks with more than 3000 physicians </li></ul><ul><li>510,000 enrollees </li></ul>HOME NEXT LAST
  6. 6. Community Care of North Carolina AccessCare Network Sites AccessCare Network Counties Access II Care of Western NC Access III of Lower Cape Fear Cabarrus Community Care Plan Central Piedmont Access II Carolina Community Health Partnership Comm. Care Partners of Gtr. Mecklenburg Community Care Plan of Eastern NC Community Health Partners Durham Community Health Network Partnership for Health Management Sandhills Community Care Network Wake County Access II Access II and III Networks – 1/04 HOME NEXT LAST
  7. 7. Community Care Networks: <ul><li>Non-profit organizations </li></ul><ul><li>Comprised of safety net providers </li></ul><ul><li>Steering committees </li></ul><ul><li>Medical management committees </li></ul><ul><li>Receive $2.50 PM/PM from the State </li></ul><ul><li>Hire care managers/medical management staff </li></ul>HOME NEXT LAST
  8. 8. What Networks Do <ul><li>Assume responsibility for Medicaid recipients </li></ul><ul><li>Identify costly patients and costly services </li></ul><ul><li>Develop and implement plans to manage utilization and cost </li></ul><ul><li>Create the systems to improve care </li></ul>HOME NEXT LAST
  9. 9. Implementing Disease Management <ul><li>Evidence-based guidelines </li></ul><ul><li>Clinical directors set performance standards </li></ul><ul><li>Local provider buy-in obtained </li></ul><ul><li>Improve the care management process </li></ul><ul><li>Local & state level technical assistance </li></ul><ul><li>Pilot initiatives </li></ul>DISEASE MANAGEMENT HOME NEXT LAST
  10. 10. Managing High Risk Patients <ul><li>Identify high cost through claims analysis </li></ul><ul><li>Identify high risk through DxCG predictive modeling </li></ul><ul><li>Targeted case management </li></ul><ul><li>Coordinate resources </li></ul>MANAGING HIGH-RISK PATIENTS HOME NEXT LAST
  11. 11. Managing High-Cost Services: <ul><li>Pharmacy </li></ul><ul><li>— Nursing home polypharmacy </li></ul><ul><li>— Prescription Advantage List (PAL) </li></ul><ul><li>Emergency Department (ED) </li></ul><ul><li>Other (pilot initiatives) </li></ul>MANAGING HIGH-COST SERVICES HOME NEXT LAST
  12. 12. Building Accountability <ul><li>Chart audits </li></ul><ul><li>Practice profiles </li></ul><ul><li>Care management reports – high-risk/high-cost patients </li></ul><ul><li>PAL scorecard </li></ul><ul><li>Progress toward goals & benchmarks </li></ul>BUILDING ACCOUNTABILITY HOME NEXT LAST
  13. 13. Current Initiatives <ul><li>Asthma </li></ul><ul><li>Diabetes </li></ul><ul><li>High cost services </li></ul><ul><ul><li>ED </li></ul></ul><ul><ul><li>Pharmacy </li></ul></ul><ul><li>High cost / high risk enrollees </li></ul>HOME NEXT LAST
  14. 14. Asthma Initiative <ul><li>First program initiative – began Jan. 1999 </li></ul><ul><li>Adopted best practice guidelines (NIH) </li></ul><ul><li>Implemented continuous quality improvement processes at each practice </li></ul><ul><li>Physicians set performance measures </li></ul><ul><li>Provide regular monitoring and feedback </li></ul>HOME NEXT LAST
  15. 15. Asthma Initiative Key Process Measures No. with asthma who had documentation of staging No. staged II – IV on inhaled corticosteriods No. staged II – IV who have an AAP HOME NEXT LAST 1 2 3 1 2 3
  16. 16. Diabetes Initiative <ul><li>Second program-wide initiative – began July 2000 </li></ul><ul><li>Adopted best practice guidelines (ADA) </li></ul><ul><li>Implement continuous quality improvement processes at each practice </li></ul><ul><li>Physicians set performance measures </li></ul><ul><li>Provide regular monitoring and feedback </li></ul>HOME NEXT LAST
  17. 17. Diabetes Initiative ACCESS II-III Diabetes Chart Audit Results Baseline (July – Dec. ’00) July – Dec. ‘01 July – Dec. ‘02
  18. 18. Community Care of NC creates an infrastructure for: <ul><li>Statewide Initiatives </li></ul><ul><li>Collaboration w/other interested partners </li></ul>HOME NEXT LAST
  19. 19. Lessons Learned <ul><li>Local buy-in a must </li></ul><ul><li>All stakeholders must be at the table </li></ul><ul><li>Incentives </li></ul><ul><li>Legislative support </li></ul><ul><li>Think outside of the box </li></ul>
  20. 20. HOME
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