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Care coordination


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Care coordination

  1. 1. Care Coordination Virginia Rural Health Association Annual Conference December 8, 2011 Chris Collins, MSW Partnering for Healthy Communities, since 19731
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 14. CCNC IC Analytics & Care Management Pharmacy Provider Information Reporting Home Portal System Services Application15
  15. 15. CCNC IC Analytics & Reporting Provider Care Management Pharmacy Home Services Portal Information System Application16
  16. 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. 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: