Beyond Implementation: Capturing the Value of Care Coordination May - - PowerPoint PPT Presentation

Beyond Implementation:

Capturing the Value of Care Coordination

May 28, 2015 11 am – Noon Central

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U43MC09134. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

2015 Webinar Series

Pediatric Care Coordination:

Beyond Policy, Practice, and Implementation

A webinar series brought to you by the National Center for Medical Home Implementation

Beyond Implementation: Capturing the Value of Care Coordination

brought to you by the National Center for Medical Home Implementation

Moderator:

Dian Baker, PhD, RN

California State University, Sacramento School of Nursing

2015 Webinar Series

Pediatric Care Coordination:

Beyond Policy, Practice, and Implementation

A webinar series brought to you by the National Center for Medical Home Implementation

Beyond Policy: Implementing Care Coordination in Practice March 30, 2015 Beyond Practice: Fostering Diverse Partnerships for Successful Care Coordination April 22, 2015 Beyond Implementation: Capturing the Value of Care Coordination May 28, 2015

AAP Care Coordination Policy Statement

.

Pediatrics, May 2014 Policy Statement from the American Academy of Pediatrics

Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems

Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee Lead Authors: Renee M. Turchi, MD, MPH, FAAP & Richard C. Antonelli, MD, MS, FAAP

Families are Key Members

• f the Team!!

Care Coordination is Important for ALL these Reasons… and More!

Objectives for Today’s Webinar

 State the value of measuring and evaluating care

coordination activities within the context of improved patient experience, improved health of populations, and decreased cost of health care.

 Identify tools and strategies to facilitate the

measurement of pediatric care coordination activities.

 Provide examples of how practices are utilizing care

coordination performance metrics and methodologies to capture value for patients and families.

Richard Antonelli, MD, MS, FAAP

Boston Children's Hospital Harvard Medical School National Center for Care Coordination Technical Assistance richard.antonelli@childrens.harvard.edu

Beyond Implementation: Capturing the Value of Care Coordination

brought to you by the National Center for Medical Home Implementation

Disclosures

 I have no relevant financial relationships with the

manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity.

 I do not intend to discuss an unapproved/investigative

use of a commercial product/device in my presentation.

National Center for Care Coordination Technical Assistance (NCCCTA)

The mission of the center is to support the promotion, implementation and evaluation of care coordination activities and measures in child health across the United States Contact: Hannah Rosenberg hannah.rosenberg@childrens.harvard.edu

The National Center for Care Coordination Technical Assistance is working in partnership with the National Center for Medical Home Implementation (NCMHI) in the American Academy of Pediatrics. The NCMHI is supported by the Health Resources and Services Administration (HRSA) of the United States Department of Health and Human Services (HHS) grant number U43MC09134.

Pediatric Care Coordination Community

States with entities that are in early stages of engagement. Expressed interest in developing care coordination workforce capacity on level of individual institution and/or state-wide program.

*some sites may have implemented since our last communication

Across these states, as of May 1, 2015, we are aware of over 20 different institutions using the Pediatric Care Coordination Curriculum as a resource.

As of May 1, 2015

(RI)

+ + + + + +

States with entities that have used the Pediatric Care Coordination Curriculum as a resource to implement care coordination workforce capacity building

+ States engaged in statewide

implementation, some partnering with Title V programs

Benefits of Developing a Community

 Sharing resources  Not “re-inventing the wheel”  Learning from others difficulties and successes  Potential for collaboration

Framework for High Value Care Delivery Model

• Medical home is an essential component of high

performing system, but it needs:

• Financing
• Work force development
• Resources which align with integrated care

structures (ie, subspecialties)

• Technology
• Collaborative Care Models

Integration is essential for success… evidence exists!

Framework for High Value Care Delivery Model

• Care Coordination is necessary but not sufficient to

achieve integration

• Care Coordination is the set of activities which occurs

in “the space between”

• visits, providers, hospital stays, agency contacts

Only way to succeed is to engage all stakeholders, including patients and families, as participants and partners

Implications for Accountability

• Measure at all levels of the system
• Transparency of performance
• Incentives supporting activities in “the space between”
• Education of work force
• Support for those activities
• Support for measurement

Boston Children’s Hospital Integrated Care: Elements Which Support a Network of Care Across the Community

Centers of Excellence Population Health Integration Collaborator

Elements of Care Integration

• Inter-Professional Education
• Communications
• Portals
• “Warm” hand-offs
• Optimal Models of Care
• Disease Specific Care

Pathways

• Collaborative Care Models
• Tele-health
• Care/ Utilization Management
• Outcomes / Value
• Quality
• Patient/ Family Experience
• Costs
• Accessibility
• Care Coordination
• Tracking & Registry
• Linkage to in-country

resources

• Integration with

specialists

Primary and Subspecialty Care

Boston Children’s Hospital

Community-based Primary Care Health Centers and Private Practices

BCH Integrated Care Program Selected Tools and Processes

• Care Coordination Capacity Building
• Pediatric Care Coordination Curriculum
• Care Coordination Measurement
• Care Coordination Measurement Tool
• Family Experience Measurement
• Pediatric Integrated Care Survey
• Assessing Hospital Discharge Readiness
• Care Transitions Measure-Pediatric
• Care Planning
• Shared Care Planning Approach, Care Coordination Strengths and

Needs Assessment

How Care Coordination is Financed:

Issues & Opportunities

• Fee-for-Service (FFS)
• FFS plus per member per month (PMPM) allowance
• Global Budget
• Caveats:
• Know TRUE costs of care
• Document care coordination activities and outcomes
• Affordable Care Act: Opportunities in Accountable

Arrangements

• Working with strategic partners
• Enterprise leadership: physician/nursing/social work
• Family partners: Federation for Children with Special Needs

(Mass Family Voices)

• Developing relationship with business community
• Payers
• National Business Group on Health
• Discussions re: value proposition of care coordination
• Outcomes tied to triple aim: better outcomes, better

experience, reduced cost

Integrated Care Pilot Project - Neurology

Creating High Quality Handoffs

20

What is a Handoff?

• Transfer of pertinent knowledge between members
• f a patient’s care team, often conducted in

anticipation of an upcoming patient encounter. What is the Goal of a High Quality Handoff?

• To enable the care team to maximize the value of

every patient interaction by ensuring relevant knowledge learned by one part of a patient’s care team is known to other members at the right time and place.

Creating High Quality Handoffs (cont’d)

21

What are the Elements of a High Quality Handoff?

• Goal of anticipated encounter, from perspective of

the family and PCP

• Relevant clinical information (eg, clinical findings,

labs, imaging results)

• Model of referral relationship (eg, one-time consult,
• n-going co-management)
• Time sensitivity of requests and action items in the

care plan

Care Coordination Framework: Key Elements

MA Child Health Quality Coalition CC Task Force www.masschildhealthquality.org/

Beyond Implementation: Capturing the Value of Care Coordination

brought to you by the National Center for Medical Home Implementation

Hannah Rosenberg, MSc

Boston Children’s Hospital National Center for Care Coordination Technical Assistance hannah.rosenberg@childrens.harvard.edu

Disclosures

• I have no relevant financial relationships with the

manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity.

• I do not intend to discuss an unapproved/investigative

use of a commercial product/device in my presentation.

Care Coordination Measurement Tool (CCMT)

• Intended to be adapted to reflect activities and outcomes of

teams in diverse settings

• Tool can be implemented in different ways depending on

goal of collecting data

• for every encounter
• nce a week
• every quarter, etc
• Paper version or web-based versions have been used in past
• In AHRQ Atlas, core tool can be found on BCH website:

http://www.childrenshospital.org/care-coordination-curriculum/care- coordination-measurement

CCMT Background

 CCMT is a value capture tool designed to track care

coordination activities that are currently being done but not being accounted or reimbursed

 CCMT works to assign value to care coordination activities

and get to a “true cost of care”

 Initially developed to be a tool used in pediatric primary

care practices as a quality improvement initiative

 CCMT is intended to be adapted by the user/s  CCMT is intended to address quality improvement and

finance

CCMT Today

• Available in public domain on BCH website
• Many institutions are using CCMT to capture value of

work that they are doing

• pediatric primary care
• adult primary care
• specialty clinics (inpatient and ambulatory)
• research settings
• family-partner organizations

Adaptation: Questions to Inform Process

• What is goal of using CCMT to collect data?
• What will data be used to inform?
• Who will be completing CCMT?
• What care coordination tasks do they currently perform?
• What outcomes occur/are prevented due to these care coordination

activities?

• Does any tool validation need to occur? (further explained later)

Implementation: Questions to Inform Process

What format will be used to complete CCMT?

• (Web/paper based?)

How often will CCMT be completed?

• (Think: goal—quality improvement/finance)

What to Focus on?

Quality Improvement

If practice/clinic/organization is:

• Focusing on re-assigning responsibilities/accountability, making sure

everyone is working at “top of their license”

• In space where already moved from fee-for-service to global budgets

Finance

If practice/clinic/organization is:

• In space to inform conversations about financing options

Validation (most necessary when addressing finance domain)

• In past, created vignettes, episode of care
• Posed to subject matter experts
• Inter-rater reliability

National Study of Care Coordination Measurement in Medical Homes

Antonelli, Stille, and Antonelli, 2008

Primary Focus % Encounters Clinical/Medical Management 67 Referral Management 13 Social Services 7 Education/School 4 Developmental/Behavioral 3 Mental Health 3 Growth/Nutrition 2 Legal/Judicial 1

Focus of Encounter: Aggregate Data

National Study of Care Coordination Measurement in Medical Homes

 Outcomes Prevented – Aggregate Data  (32%) of total 3855 CC encounters had something prevented  Of the 1232 CC Encounters where prevention was noted as an outcome: Outcome Prevented # Care Coordination Encounters Percentage Visit to pediatric office/clinic 714 58 Emergency department visit 323 26 Subspecialist visit 124 10

National Study of Care Coordination Measurement in Medical Homes

 62% of RN CC Encounters prevented something  33% of MD CC Encounters prevented something  Non-revenue-generating office nurses drive the most system-level cost savings: avoidance of ED and office visits

Suggestions

• Involve people who will be collecting data in the

adaptation process

• Ensure that everyone using the tool is working from

common definitions, terms (tip: vignettes are helpful in this case)

• Before actual data is collected,

complete trial using a paper version

• f the tool for staff to get used to

using tool

Steps to Get This Done

• Decision to Proceed
• Why?
• How long to commit?
• Expected Outcomes
• Create Episode of Care model
• Modify CCMT
• Implement CCMT
• Incorporate CCMT in electronic format

CCMT Use: Boston Children’s Hospital

• Developed REDCap Tool
• Link available in EMR
• Spent time usability/feasibility testing
• Integrated Care Program
• Martha Eliot Health Center, Behavioral

Health Population

Beyond Implementation: Capturing the Value of Care Coordination

brought to you by the National Center for Medical Home Implementation

David K. Urion, MD

Boston Children's Hospital Department of Neurology david.urion@childrens.harvard.edu

Disclosures

• I have no relevant financial relationships with the

manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity.

• I do not intend to discuss an unapproved/investigative

use of a commercial product/device in my presentation.

Baseline Subspecialty Utilization

40

Department of Neurology, Boston Children’s Hospital

First phase of testing: feasibility/usability of CCMT in clinic

Current Quality of Referrals

• Integration Quality Initial Referrals into Neurology

Presence of a referral request: 6.7% Presence of an in-house referral mentioned in a BCH clinical note: 33.3%

• Integration Quality for Follow-up Visits

For patients coming into these pilot sites, little documentation existed regarding source of referral, initial reason for the referral, and expectations of PCP , if any. Follow-up visits generally have no structured mechanism by which the PCP communicates with the subspecialist about new or on-going expectations or

• needs. Communications are ad hoc or solely dependent on the patient,

family, or caregiver to relay to other members of the patient’s care team.

Closing the Loop

Getting Results Where They Need to Be on Time

Visits resulting in a lab order 47% Lab order completed 75% Family notified of the test results 77% Referring MD notified

• f the test

results 38% Findings based on close the loop measurements conducted for 130 visits across eight clinics in the Department of Neurology from May 2014 to February 2015. Visits resulting in a consult order 21% Consult order completed 48% Neurologist received consult note 92%

Improving Care Transitions

Using close the loop measures to confirm improvements in completing lab orders and communicating results in the Rett Clinic:

• Baseline measurements taken from

October 2013 to March 2014.

• Intervention started April 2014 with

weekly team conferences to discuss task ownership and order status.

• Process shifted to an electronic

communication process to better fit the team’s workflow.

* Q2 2015 data through January and February.

Pediatric Integrated Care Survey (PICS)

In the Process of Validation

Funded by Lucile Packard Foundation Children’s Health

More than one hundred families of children with complex care needs have responded to a survey designed to capture the family perspective on care integration.

Beyond Implementation: Capturing the Value of Care Coordination

brought to you by the National Center for Medical Home Implementation

Tami Chase, RN

Nurse Manager Martha Eliot Health Center tami.chase@childrens.harvard.edu

Disclosures

• I have no relevant financial relationships with the

manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity.

• I do not intend to discuss an unapproved/investigative

use of a commercial product/device in my presentation.

Martha Eliot puts CCMT into Practice

Martha Eliot Health Care

• urban primary care practice
• essential part of its community

for more than 40 years

• medical home serving low-

income housing development and greater Boston community 85% Medicaid, the patient population at Martha Eliot is vulnerable, with poor health status; sizeable CYSHCN population. Significant growth in the Mental Health Department is expected in 2015-2016.

Utilizing the CCMT at Martha Eliot

• A new position for the Mental Health Department hired

August 2014

• The role of the RN provides a layer of clinical management,

education, inter-visit and care coordination necessary to meet the complex needs of our population

• The vision of mental health services at Martha Eliot is to be

a leader in the provision of community mental health care

• CCMT is improvised for Mental Health and used in the EHR
• CCMT captures data for six months

Martha Eliot Demonstrates the Use of CCMT

• 155 encounters were entered by the RN in a 3 month

period between 12/11/14-3/11/15.

• Data demonstrates clinical expertise of a RN needed in

the Mental Health Department

• Improvements were seen in:
• compliance to patient visits
• responsiveness to situation of high patient acuity
• improved rates in medication compliance
• preventable patient outcomes

Martha Eliot Demonstrates the Use of CCMT

• Example Data Points used:
• As a result of this care coordination activity, abrupt

medication discontinuation by patient/caregiver was prevented 74.2% of the time (115 times) an encounter was recorded

• As a result of this care coordination activity, medication

treatment continuity and compliance occurred 81.3% of the time (126 times) an encounter was recorded

• In 97.4% of the encounters recorded, clinical

competence was required

Questions

Resources

• Patient- and Family-Centered Care Coordination: A

Framework for Integrating Care for Children and Youth Across Multiple Systems (AAP Policy Statement)

• Building Your Medical Home: Care Coordination

(Resource Guide)

• Fostering Partnership and Teamwork in the Pediatric

Medical Home: A “How-To” Video Series

• National Center for Medical Home Implementation:

Care Coordination (Additional care coordination resources)

And More Resources

• Pediatric Care Coordination Curriculum
• Care Coordination Measurement Tool
• Care Coordination Measures for Primary Care Practice

(AHRQ)

• MA Child Health Quality Coalition
• National Center for Care Coordination Technical

Assistance at Boston Children’s Hospital

• Hannah Rosenberg, Manager:

Hannah.Rosenberg@childrens.harvard.edu

We’re Here to Help You!

Have a question about medical home? Contact the National Center for Medical Home Implementation! www.medicalhomeinfo.org Medical_home@aap.org Subscribe to our Listserv! 800/433-9016 ext 7605