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  • 1. Care Coordination Virginia Rural Health Association Annual Conference December 8, 2011 Chris Collins, MSW Partnering for Healthy Communities, since 19731
  • 2. • Provides comprehensive recruitment assistance to communities and practices that serve underserved residents since 1975 • Average placements per year over the past 6 ORHCC fiscal years (FYs): 1492 OHRCC = Office of Rural Health and Community Care
  • 3. • 20 yrs ago began assigning Medicaid Recipients to a medical home • Primary Care Providers responsible for medical care coordination / 24 hour access DMA • Currently 2,000 participating practices PCP DMA = Division of Medical Assistance3 PCP = Primary Care Provider
  • 4. Medicaid Supports Primary Care Providers • Maintains a high fee for service payment of 95% of Medicare. • Created regional networks that provide community health teams that are a member of the primary care providers care team for high risk recipients. • Pays a pm/pm to cover the cost of care coordination • Base payment of $1.00 for coverage and specialist coordination • Increased to $2.50 when they join a regional CCNC network • Increased to $5.00 when the recipient is Aged, Blind or Disabled •Policy to strengthen the primary care infrastructure: • Integrating behavioral health services • Cover nutritional services for children • Require targeted case managers to link with primary care4 CCNC = Community Care of North Carolina
  • 5. • 13 years ago began creating Community Care of North Carolina (CCNC) Networks. • Currently have 14 Regional Networks in all 100 counties. • Every network provides community health teams with local ORHCC / DMA care managers (600), pharmacists (26), psychiatrists (14) and medical directors (20) to improve local health care CCNC delivery5
  • 6. The State identifies priorities and provides financial support through an enhanced PMPM payment to community networks of $3.72 and $13.72 for the Aged Blind and Disabled. • Nurse and social worker care management of high-risk patients • Chronic Disease Management Initiatives (e.g. Asthma, Diabetes) • Complex co-occurring chronic conditions • Hospital Transition Care • Emergency Department Utilization • Pharmacy Initiatives • Palliative Care • Mental Health Integration / Chronic Pain • Pregnancy Medical Home6
  • 7. Care Management Activities: • Risk Stratification/ Identify Target Population • Screening/Assessment/Care Plan • Medication Reconciliation, Polypharmacy & PolyPrescribing • Referral / Linkage • Self Management of Chronic Disease Network Regional Activities: • Enrollment/Outreach • Population Health Management • Quality Improvement Initiatives • Clinical Leadership • Integration of Physical and Mental Health • Informatics Center Centralized Statewide Activities: • Advocacy • Contract Negotiations • Clinical Leadership8 • Informatics Center
  • 8. • State web based Case Management Information System (CMIS) • Health record, assessment, care plan, goals, measures and task management, and secure communication CMIS • Linked additional data sets to CMIS: claims, pharmacy, labs • Informatics Center (IC) • Linking additional data sources • Analytics, Population Assessments, Risk Stratification, IC Utilization Monitoring, Tracking of Care, Quality Measures, and Key Performance Indicators.9
  • 9. Quality: Independently evaluated by AHEC auditors • CCNC in the top 10 percent in US in HEDIS for diabetes, asthma, heart disease compared to commercial managed care. Cost savings/ Effectiveness: Independently evaluated by the state and third-party consultants (Mercer and Treo Solutions). • More than $700 million in state Medicaid savings since 2006. • Adjusting for severity, costs are 7 % lower than expected. Costs for non-CCNC patients are higher than expected by 15 percent in 2008 and 16 percent in 2009. • For the first three months of FY 2011, per member per month costs are running 6 percent below FY 2009 figures. • For FY 2011, Medicaid expenditures are running below forecast and below prior year (over $500 million).10
  • 10. • ORHCC • Health Net: • Medical Home • Prescription Assistance • Uninsured care coordinators using CMIS ORHCC • Shadow claims • Community Care of North Carolina for Uninsured Parents (CCNC-UP) – State Health Access Program (SHAP) Grant • DMA • Moving Duals into CCNC • Linking specialists to CCNC • Health Check Coordination for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) using CMIS DMA • Adding Children’s Health Insurance Program (CHIP) recipients to CCNC • Expanding with Health Home State Plan Amendment11
  • 11. • Division of Public Health (DPH) • Public health care coordinators using CMIS (high risk pregnancy and at risk children) • Data (immunization, vital records) DPH • CDC Community Transformation Grant • Division of Mental Health, Developmental Disability and Substance Abuse Services (DMHDDSA). • Agency for Healthcare Research and Quality (AHRQ) grant to integrate facility and provider data on Medicaid and uninsured recipients into the IC • SAMHSA Grant for Screening Brief Intervention Referral and Treatment DMHDDSA (SBIRT) in Primary Care12
  • 12. • CMS Multi Payer – Increases payment to the medical home, adds care coordination benefits and provides claims data in seven rural counties. • Medicare CMS • State Health Plan MAPCP • Commercial Plan • First In Health • Employers • Fund medical homes • Wave primary care co-payments Employers • Add care coordination benefits13 MAPCP = (Medicare) Multi-Payer Advanced Primary Care Practice (Demonstration)
  • 13. Surescripts Mental health Pharmacy Clinical outcomes Claims data Multi- Payer Medicaid / Uninsured Enrollment Claims data 646 / Multi-Payer* Shadow claims Medicare / Dual State Health Plan* Medication Assistance State Facility Data ** Commercial* ORHCC Uninsured Immunizations Chart Audits Vital Records Enrollment Public Health* Claims CCNC Lab Real time Hospital Informatics (IP/ER) Center Health Medicaid Information Exchange** CHIP* and EHR* *planning & implementation phase14 IP = In-patient | ER = Emergency Room | EHR = Electronic Health Record ** discussion phase
  • 14. CCNC IC Analytics & Care Management Pharmacy Provider Information Reporting Home Portal System Services Application15
  • 15. CCNC IC Analytics & Reporting Provider Care Management Pharmacy Home Services Portal Information System Application16
  • 16. Empowering Networks and Providers to Deliver Coordinated CareDirect access to IC softwareCCNC / Health Net Providers CMIS usersCCNC (Medicaid / HealthNet) Networks CCNC Medicaid (600)Mental Health Networks (LME) Health Net Uninsured (50)Local Health Departments Public Health (500)Local HospitalsState Facilities17 LME = Local Management Entity
  • 17. Chris Collins, Deputy Director NC Office of Rural Health and Community Care 2009 Mail Service Center Raleigh, NC 27699-2009 Telephone: (919) 733-2040 Email: Website: