Care Coordination Efforts
Assessing the extent and efficacy of existing care coordination efforts will enable states to identify gaps and overlaps, thus enabling them to make informed decisions to reallocate resources, enhance existing efforts or launch new efforts.
*Milestone details:
*Full name: Assess the degree to which programs that provide care coordination functions exist in the state and develop new or support existing efforts to expand care coordination.
*Relevance to the ACA:
Enhancing care coordination – especially for vulnerable populations – is an aim of many ACA programs and initiatives. Some of the most relevant ACA opportunities to promote care coordination include:
§1311 – Health plans participating in health insurance exchanges will be required to report on quality improvement strategies such as care coordination.
§2602 – Federal Coordinated Health Care Office to support state efforts to improve coordination of care for duals.
§3021, §10306 – Mandate of new CMS Center for Medicare and Medicaid Innovation includes promoting care coordination.
A variety of other sections of the ACA also offer promise for improving care coordination, but with a more limited state role. In particular, Medicare is to launch an ACO program (§3022), a payment bundling pilot (§3023), an Independence at Home Demonstration (§3024), and a Community-Based Care Transitions Program (§3026).
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District of Columbia
In the May issue of Health Affairs, James Robinson reports on his research of two varying approaches to both constrain costs and improve care: one approach involves greater integration, coordination, and global payment while the other involves specialization and episode payment. By comparing two high volume hospitals, Robinson finds that coordination of patient care is an important factor in success but that specialization also creates efficiencies.
Alabama
This is a topic I'm starting to see more specific discussion about, particularly around models and software platforms that may allow for better coordination across providers? It's a little scary this topic hasn't had anything new posted in almost a year. What activity are you seeing around care coordination in your states?
Florida
Hi Kristopher,
I am with the Cúram Software group within IBM. You may or may not be aware of Cúram, but we have traditionally been very involved in traditional Health & Human Services programs (Medicaid Eligibility, TANF, SNAP, Disability), but increasingly we are involved in leveraging the capabilities of Cúram for healthcare coordination in both state & local government and the private insurance and healthcare space.
I would be happy to discuss this further with you if you'd be interested.
Thanks,
Jeff Mann
jmann@us.ibm.com
District of Columbia
Those interested in this topic may wish to see these recent announcements from CMS:
- Guidance on integrated care models: http://www.statereforum.org/discussions/care-coordination-financing#comm...
- State Innovation Models Initiative: http://www.statereforum.org/discussions/medicaid#comment-11127
District of Columbia
The AARP Public Policy Institute has released a new paper, Moving Toward Person- and Family-Centered Care, authored by Lynn Feinberg. Although the concept of person- and family-centered care (PFCC) has gained attention in recent years as a mechanism for transforming health care and long-term services and supports (LTSS), it has not yet been fully integrated across health care and LTSS as an essential part of all care and support. This paper describes what person- and family-centered care is, and discusses why many experts believe it improves care and quality of life for older adults and for their families.
Oregon
In October 2011, Oregon launched its Patient-Centered Primary Care Home (PCPCH) Program with the goal of providing access to a PCPCH for 75% of all Oregonians by 2015. To support Oregon's providers in acheiving this model of care, the Office of Oregon Health Policy & Research within the Oregon Health Authority is seeking proposals from an entity (or a collaborative of organizations) to propose a creative solution to provide technical assistance to facilitate adoption of the PCPCH model and establish a Center for PCPCH Practice Transformation.
Proposals are due on April 30. If you would like to learn more, please attend the pre-proposal conference on Tuesday, April 3 from 1:00-3:00 PST. Please rsvp to Lesley G. Erickson, (503) 945-6698, lesley.g.erickson@state.or.us if you will be attending and she can provide a call-in number. In fact, all questions on the RFP and the procurement process must be addressed by Lesley, who is the sole point of contact for the solicitation.
The RFP is OHA-3388-12. To look at the RFP, you must follow a few steps. First, go to the Oregon Procurement Information Network (ORPIN) site at http://orpin.oregon.gov/open.dll/welcome. If you’d just like to look at a brief summary of the RFP, follow these steps: on the left-hand side, click on “browse,” then “browse opportunities,” then “open opportunities.” To find OHA-3388-12, you need to scroll through the many pages of open opportunities, which are sorted by close date (most recent close dates are first). Since OHA-3388-12 closes on April 30, you’ll need to scroll down (when I checked earlier today, it was #113, on page 4, but obviously that will change over time). In order to see the full RFP, however, you’ll have to register with the ORPIN website. To do this, go to the main page (once again, that’s http://orpin.oregon.gov/open.dll/welcome) and click on “supplier registration” on the left-hand side. Then, you’ll be able to search for OHA-3388-12. For further assistance with the ORPIN website, please call the ORPIN Help Desk at (503) 378-4642.
Maine
State Refor(u)m is pleased to share this overview of six state projects that help providers deliver high-powered primary care. State Refor(u)m's new "Fast Facts on Primary Care Practice Support Systems" profiles:
• the Patient Care Networks of Alabama,
• the Community Care Teams of Maine,
• the New York Adirondack Region Medical Home Pilot Pods,
• Community Care of North Carolina,
• the Oklahoma Health Access Networks, and
• the Vermont Blueprint for Health Community Health Teams
Consult the attached matrix to learn how the teams, pods, and networks support practices, draw on federal health reform resources, and much more.
Minnesota
Minnesota is continuing to explore and test our health care home (HCH) initiative. In June of 2011 we awarded three providers a Community Care Team Planning Grant. The three providers were either already certified as a HCH or would be certified before the end of the grant period.
• Three Community Care Team Grants were awarded with the purpose of designing, documenting and implementing a community care team that addresses community priorities, care coordination, transitions management and effective use of resources, and engages in collaborative activities with certified health care homes. The community care team will work together to provide outcomes-oriented care guided by the principle of optimizing clinical outcomes for community members to meet the goals of the Institute for Healthcare Improvement’s Triple Aim: improved health outcomes, enhanced patient experience and reduced costs/improved value.
Community Care Team Grant recipients are:
o Hennepin County Medical Center, which will focus efforts on their diverse ethnic and cultural populations.
o Essentia Health Care Ely Clinic, which will focus efforts around children, adolescents and adults with mental illness.
o Mayo Clinic, which will focus efforts on community dwelling older adults with multiple chronic conditions.
I've enclosed our RFP and Q & A documents as well as the links to two articles we shared with grant applicants about the North Carolina and Vermont programs who we looked to as models in our development of our community care team RFP.
Vermont’s Blueprint For Medical Homes, Community Health Teams, And Better Health At Lower Cost http://content.healthaffairs.org/content/30/3/383.full
Community Care of North Carolina: Improving Care Through Community Health Networks http://www.annfammed.org/content/6/4/361.full.pdf+html
Connecticut
The Patient Centered Medical Home Advisory Committee issued this report that addresses this milestone.
Virginia
In Virginia, we are beginning to roll out "care coordination" models for populations that have traditionally been paid for through fee for service. As we contemplate enrolling individuals with behavioral health (i.e., mental health) needs in these new Medicaid models, I'm curious about the fiscal impact that other states have either experienced or are modeling, since we will begin doing the same soon. Any guidance you can provide would be appreciated.
Maine
Hi Joe,
Two resources come to mind:
1) Community Care of North Carolina, which focuses on managing the care of Medicaid beneficiaries (and now, select other populations), has consistently shown savings. FMI: http://www.communitycarenc.org/about-us/update-archive/results-update/. In particular, see pages 6 and 7 of this document: http://www.communitycarenc.org/elements/media/related-downloads/treo-ana...
2) Missouri's use of community mental health centers (CMHCs) for case management has produced some interesting data on savings. FMI: http://www.psychiatricannalsonline.com/showPdf.asp?rID=67390 I'm not sure how relevant their experience is given your plans, but perhaps it might be useful.
Hope this helps!
District of Columbia
Texas uses an electronic Health Passport to ensure continuity of care for children in the foster care system. This presentation by Kay Ghahremani describes the Health Passport.
District of Columbia
The Patient-Centered Medical Home (PCMC) 2011 Recognition Program is a powerful tool for transforming primary care into what patients want it to be.
NCQA PCMH 2011 Recognition standards provide a roadmap for making this powerful change in how clinicians provide care. The clear and specific criteria show how to organize care around patients and work in teams to coordinate, track and
improve their care.
Please refer to the attached fact sheet for further information.
To learn more, please contant the NCQA Public Policy Department at 202-955-1709 or visit www.ncqa.org.
Maine
Those interested in Oregon's progress in this area may wish to see State Rep Mitch Greenlick's post here: http://www.statereforum.org/node/3422
Maine
Utah and Idaho jointly submitted a successful CHIPRA Demonstration Grant proposal to, "develop a regional quality system, guided by the Medical Home model, to enable and assure ongoing improvement in the healthcare of children enrolled in Medicaid/CHIP programs. The project will focus attention on improving care and outcomes for children and youth with special health care needs" (proposal abstract). The project is referred to as the Children's Healthcare Improvement Collaboration or CHIC. To learn more, please see the proposal at left or visit: http://medicine.utah.edu/upiq/CHIC-CHIPRA/index.htm.
Virginia
The Synthesis Project recently completed another synthesis relevant to this topic. Mental Health and Medical Comorbidities, authored by Ben Druss, synthesizes the literature on the high rate of physical comorbidities among persons with a mental health diagnosis. The research synthesis and policy brief are attached here.
Virginia
The Synthesis Project, an initiative of the Robert Wood Johnson Foundation, recently completed a synthesis of the literature on care management. The synthesis, authored by Tom Bodenheimer, is titled Care Management for Patients with Complex Health Care Needs. The research synthesis and the policy brief are uploaded here.
Maine
Care coordination is a key hallmark of the medical home model. Massachusetts has launched a multipayer medical home pilot. To learn more, please follow this link: http://www.statereforum.org/node/2206
California
Cabin Creek Health Systems is a federally-qualified health center in West Virginia. The organization partnered with the local community and technical college system to provide advanced training to medical assistants to prepare them to help implement a Senior Medical Home program. The team of experienced medical assistants provides risk assessments and care coordination to elderly patients, and conducts home visits to frail elderly patients in remote rural areas. This case study is an interesting example of an effort in care coordination and in an attempt at starting a statewide initiative to address the training needs of medical assistants working in the state's community health centers.
Maine
To learn more about West Virginia's Medical Home Incentive Pilot, please see the following presentation: www.pcpcc.net/files/medical_home_incentive_pilot_pcpcc_presentation.ppt
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