contact: [email protected] 202.684.7457 care coordination: coordinating...

Contact: [email protected]

202.684.7457

www.TheNationalCouncil.org

Care Coordination:Care Coordination:Coordinating Supports, Services, Coordinating Supports, Services,

& Health Care& Health Care

Jeff Capobianco, PhD, LLP National Council for Behavioral Health


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Overview

1. Health Home & Other National Drivers of Improved Care Coordination

2. Defining Care Coordination

3. “Health Home” Care Coordination: Lessons Learned from the Field


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Healthcare System 2014

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The Triple Aim

Targets identified by Don Berwick (former director of the Center for Medicaid/care Services & Institute for Healthcare Improvement) that new approaches to healthcare services provision should aim to achieve:

1.Improving the Health of Populations of People

2.Bending the Cost Curve

3.Improving the Patient’s Experience of Care

Source: Berwick, Nolan, & Whittington (2008).

The Triple Aim: Care, Health, & Cost.

Health Affairs. vol. 27 no.3, 759-769.

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The Affordable Care Act

• Medicare Accountable Care Organizations

• Health Insurance Exchanges (HIX)/Health Insurance Market Place

• Health Information Exchanges (HIE)

• Variety of State Based Waivers (e.g. Health Home)


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So Many Terms so Little Time…


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The Accountable Care Organization

While extremely similar to the players in the alphabet soup of managed care players in the 1990s…ACOs differ significantly:

1.Accountability rests with the providers, rather than the health insurers

2.No health plan intermediary is required to contract with the provider organization

3.Great flexibility in their provider composition

4.Allow for payment under a fee-for-service arrangement

5.Are required to provide primary care

6.Have quality metrics tied to funding

Source: ACOs and other options: A “how-to” manual for physicians navigating a post-health reform world 4 th edition http://www.ama-assn.org/resources/doc/psa/physician-how-to-manual.pdf


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Source: LeavittPartners.com


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ACO Cost Findings

Differences In Spending Growth For All Pioneer ACO-Aligned & Comparison Market Beneficiaries, By Medicare Service, Per Beneficiary

Per Month, 2011 To 2012 source: Data from CMS Feb 2014 Report

Service

Pioneer ACO Difference Compared

Local Market (Green = Savings)

Pioneer ACO Difference Compared Separate Geographic

Market (Green = Savings)

Total $19.97 $18.86Outpatient $3.10 $1.80Physician $2.34 $0.69Inpatient $3.91 $8.93

Skilled nursing facility $0.98 $0.80

Home health $0.84 $0.81

Hospice $0.10 $0.09

Durable medical equipment $0.04 $0.03


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ACO Clinical Findings

Top Five Performing Pioneer ACOs Source: CMS March 2014

ACO Name Number of Members

Diabetes Measure 1

Diabetes Measure 2

Diabetes Measure 3

Diabetes Measure 4

Coronary Artery

DiseaseAllina Health 15,000 83% 88% 86% 100% 87%

Park Nicollet Health Services ~15,000 78% 82% 82% 99% 94%

Bellin-Thedacare Healthcare

Partners~15,000 84% 83% 83% 92% 82%

Fairview Health Systems 19,000 78% 81% 85% 97% 86%

Atrius Health 55,000 80% 84% 89% 83% 86%


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Medicaid ACO Models

Common Wealth Fund Medicaid ACO Learning Collaborative:

• Colorado

• Maine

• Massachusetts

• Minnesota

• New Jersey

• Oregon

• Vermont


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States to Watch Re: I/DD HH

• Arizona, Michigan, & Wisconsin currently include people with I/DD in their managed long-term services and supports programs.

• Findings include improved access to long-term services and supports, improved coordination of care, and enhanced beneficiaries’ choice of providers.

(Source: R. Gettings, “Reassessing the Impact of Managed Care in the Developmental Disabilities Sector,” The National Leadership Consortium on Developmental Disabilities,

2009 1(1). Available at: http://www.nasddds.org/pdf/PolicyInsightsBulletin(March2009).pdf.)


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• New York-- Developmental Disabilities Individualized Support & Care Coordination Organization (DISCO)

• New Jersey-- Arc of Monmouth became PCMH

• Rhode Island-- Children’s Focus

• Arkansas-- of course!!

(Source: Structuring New Service Delivery Models for Individuals w/ I/DD. Lind & Archibald, CHCS Policy Brief;

Feb. 2013)

States to Watch Re: I/DD HH


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What is a Health Home?

• A State Waiver to drive System Level Transformation

• Eligible individuals:

2 chronic conditions; or

1 chronic condition and is at risk of having a second chronic condition; or

1 serious and persistent mental health condition


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Person/Pt. Centered Medical Home: Key Components

• Ongoing relationship with a medical provider who is trained to provide first contact, continuous, and comprehensive care

• An informed and activated patient/person and support network

• Whole person orientation

• Care is co-managed by a team who collectively take responsibility to provide or arrange for care

• Span of life care: Levels of care include acute, chronic, and preventive

Source: http://www.integration.samhsa.gov/clinical-practice/CIHS_Health_Homes_Core_Clinical_Feature

s.pd


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Person/Pt. Centered Medical Home: Key Components

• Care interfaces with family and community context as appropriate

• Care is Coordinated

• Quality and Safety are hallmarks

• Robust Health Information Technology Capabilities

• Enhanced Access to care is available

• Payment appropriately recognizes the added value

Source: http://www.integration.samhsa.gov/clinical-practice/CIHS_Health_Homes_Core_Clinical_Feature

s.pd


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Integrated Health

“At the simplest level, integrated I/DD & physical health care occurs when specialty & primary care providers work together to address all the healthcare needs of people w/ I/DD.

Integration can be bi-directional: either (1) specialty I/DD services introduced into primary care settings, or (2) primary health care introduced into specialty I/DD.”

Source: Butler M, Kane RL, McAlpine D, Kathol, RG, Fu SS, Hagedorn H, Wilt TJ. Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 09- E003. Rockville, MD.

Agency for Healthcare Research and Quality. October 2008.


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Fully Integrated Model

(Best)

Co-location Model

(Better)

Referral Model

(Good)

- Systematically combining physical and I/DD services

- Most common model of integrated care

- Weakest Integrated health care model b/c based on referral

- Team care approach to mental health based in community beh health, primary care, or hospital setting

- PCPs develop agreement with I/DD providers to whom they refer their patients with beh health needs to on-site behavioral health services

-Partnership between the physical health and I/DD providers to manage the treatment of mild to moderate and stable severe psychiatric disorders in primary care settings

- Integrated team within single organization

- Providers in same location however…”co-location doesn’t necessarily mean integrated”

- Separate locations and organizations sharing information


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Service Delivery and Payment Reform

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Prevention, Early Intervention,

Primary Care, and Behavioral Health

Inpatient & Institutional

Needed Resource Allocation

All things Inpatient and Institutional

Prevention, Primary Care, BH

Current Resource AllocationIt’s about Inverting the Resource Allocation Triangleso that:

• Inpatient and Institutional Care are limited

• Chronic conditions are care coordinated in the community


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Movement to Invest in BH

BH is attractive to investors b/c: •Growing Market: National expenditures on BH are expected to reach $239 billion in 2014, up from $121 billion in 2003 ( 7% compounding growth rate).

•Favorable Legislation: Includes ACA, Parity, Carve-in approaches, & states moving to Managed Medicaid.

•Diverse Payer Mix: Medicare, 3rd Party, Medicaid (seen as most risky)

•Attractive Financing Model: Compared to general acute care hospitals margins=mid-teens, inpatient behavioral healthcare margins = 20-40% for acute hospitalization & 15-25% for residential treatment w/ maintenance at 2% of revenue.

•Niche Markets: BH with untapped “Downsize fitness” business models.

Private equity investors accounting for roughly 30% of overall activity during 2010 & 2011.

(Source: Jon Hill; Triple-Tree.com)

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Population Based Care…

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• Jeffrey Brenner - COMPSTAT >> HEALTHSTAT in Camden NJ - Care managed 1% of 100,000 people that used 30% of costs

• Behavioral health identifies people who represent top 5% to 10% of high cost consumers with a MH/SUD diagnosis in a state/community


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Health Affairs: VA Lewis, et al. “The Promise and Peril of Accountable Care for Vulnerable Populations: A Framework for Overcoming Obstacles.” 2012.

Here

Specialty I/DD health niche: caring for complex, costly patients


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I/DD Providers are Ready!

I/DD providers have been doing person centered complex care coordination for years!


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However, We Must Improve Our Care Coordination!


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Care Coordination

“the deliberate organization of patient care activities between two or more

participants involved in a person’s care to facilitate the appropriate delivery of health

care services.”

Source: McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7—Care Coordination. Rockville, MD: Agency for Healthcare Research and Quality,

U.S. Department of Health and Human Services; June 2007.


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Care Coordination…a BIG Concept…


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Perspectives on Care Coordination

Person & FamilyHow easy is it for me to get the care I/my loved one needs?

Healthcare ProviderHow easy is it for me to do my work?

System RepresentativesHow easy is it for me to know care of high quality and cost effective?

Source: McDonald, Schultz E, Albin L, et al. Care Coordination Atlas Version 3.

AHRQ Publication No. 11-0023-EF. Rockville, MD:

Agency for Healthcare Research and Quality. November 2010.


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Principles of Care Coordination

• Person Centered

• All Staff, Consumers & their Supports are Accountable

• Population-focused

• Outcome Driven- Measured


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• Proactive, Planned, & Comprehensive

• Emphasizes Cross-Organizational Relationships/Agreements & Connectivity

• Equitable

• Safe

Principles of Care Coordination


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Care Coor. Readiness Checklist

Leadership Articulating Vision/Mission Access to Care Financing Health Information Tech./Data Management/Cont. Qual.

Improvement Team Based Care Health Network Relationships Evidence Based Care Staff Training/Support Consumer & Family Inclusion


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Leadership

• Simple clear articulation of the organization’s Vision for HH

• Robust Communication Plan

• Work Plan with Measurable Targets & Timelines

• Entrepreneurial Mindset


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Access to Care

• Same Day/Next Day is becoming the Standard

• Centralized Scheduling

• Comprehensive PH/BH Screening

• Transportation Support

• Telemedicine Approaches

• Must know who isn’t coming to you for services


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Financing

• Must understand how to back-into episode of care payment approaches

• Partner with Primary Care to share costs/increase efficiencies

• Find where you are loosing money (e.g., no shows, inefficient workflows, lack of prevention/early detection, lack measurement etc.)


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HIT/DM/CQI

• Technology must support work flows (e.g., data based decision making, dashboards, etc.)

• What you don’t measure will hurt you

• If you only have paper use excel to begin managing your data

• Consider outsourcing HIT/DM or networking so can focus staffing up CQI


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Team Based Care

1. Defining appropriate team goals

2. Clear role expectations for team members

3. A flexible decision-making process

4. The establishment of open communication patterns

5. The ability of the team to “treat” itself

Source: Leipzig, Hyer et al. (2002). Attitudes Toward Working on Interdisciplinary Healthcare Teams: A Comparison by Discipline J Am Geriatr Soc 50:1141–1148.


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Health Network Partnerships

• Conduct a community assessment of social service and health care provider services

• Reach out to the providers you don’t know

• Develop stronger networks for those you do know to begin sharing information

• Target hospitals, ACO’s, and Fed. Qual. Health Center’s


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Evidence Based Care

• I/DD providers must understand the EBP for screening/assessment and treatment of physical health conditions

• Assess the use of evidence based approaches to care provision (e.g., motivational interviewing, tobacco cessation, etc.)

• Use HIT to support tracking EBP fidelity


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Staff Training/Support

Staff want to know:

•What should I stop doing?

•What should I keep doing the same?

•What should I do differently?

•Seek out avenues for cross-training between PC and I/DD staff

•Target use of data to inform staff/teams about how they are coordinating care and Screening/monitoring of PH conditions


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Consumer & Family Inclusion

• Consumers & Families are critical to team based care approach

• Must include consumers & family members in new policy/procedure development & work plan implementation

• Leverage consumer & family’s existing relationships with PC supports your staff may not have engaged


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Remember Sometimes Progress is Hard to See Unless you Dig Below the Surface!

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Some helpful links:

• http://www.integration.samhsa.gov/ (Great resource on everything integration)

• http://www.integratedcareresourcecenter.com/ (Website detailing what is happening with health reform in each state)

• http://www.chcs.org/ (Website focused on publicly funded healthcare and the transformations underway)

• http://www.h2rminutes.com/main.html (Updates on the ACA for professions—great site to sign up for email notices)


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Care Coordination Resources:

• Reducing Care Fragmentation: A Toolkit for Coordinating Care. (Prepared by Group Health’s Mac Coll Institute for Healthcare Innovation, supported by The Commonwealth Fund), April 2011.

• Making care coordination a critical component of the pediatric healthcare system: A multidisciplinary framework. New York: The Commonwealth Fund; 2009

• Care Coordination Atlas Version 3, AHRQ Publication No. 11-0023-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2010.

• Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press. 2013


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Bundled Payment Resources

American Hospital Association: Issue Brief Moving Towards Bundled Paymenthttp://www.aha.org/content/13/13jan-bundlingissbrief.pdf

CMS Bundled Payments for Care Improvement: Learning & Resources Area http://innovation.cms.gov/initiatives/Bundled-Payments/learning-area.html

Transitioning to Episode Based Carehttp://www.chqpr.org/downloads/TransitioningtoEpisodes.pdf

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Health Home for I/DD

Health Care for Individuals with Intellectual and Developmental Disabilities: An Integrated Health Home DD Model

Kastner & Walsh


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Thank You!

Jeff Capobianco

[email protected]

734.604.2591

contact: [email protected] 202.684.7457 care coordination: coordinating...

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