Care Coordination Collaborative Learning Session #5...The Impact of Co-Occurring Conditions...

Care Coordination Collaborative Learning Session #5

Wednesday January 21st , 2015

Welcome! • Introductions • Agenda Overview

Agenda Overview

Time Topic

8:15-8:30 Welcome, Introduction, & Overview of Learning Session #5

8:30-9:45 3 Team Presentations

9:45-10:30 Team Table Top Discussions: Care Management/Sustainability and Spread

10:30-10:45 BREAK

12:00-1:00 LUNCH

1:00-2:15 Final Review of CCC Assessment

2:15-2:30 BREAK

3:45-4:45 Teams Acknowledgment/Celebration

4:45-5:00 A Look at Day 2 and Adjourn

LEARNING SESSION 5 KICK OFF: What a journey we have had together!

Marc Avery, MD University of Washington, AIMS Center

& Gale Bataille, MSW

California Institute for Behavioral Health Solutions

The Impact of Co-Occurring Conditions

Untreated and/or Poorly managed MH, SUD, and Physical Health Conditions Lead to unnecessary:

Suffering Disability Expense Mortality

Effects are Bidirectional

High Degree of Overlap Between Populations Washington State General Assistance (Uninsured)

Population

There are solutions:

Why make care coordination a priority?

Patients and families hate it that we can’t make this work. Happier

clients/patients

Poor hand-offs lead to delays, lapses in care, adverse drug effects, and other problems that may be dangerous to health.

Fewer problems

Enormous waste is associated with duplicate testing, unnecessary referrals, unwanted specialist-to-specialist referrals, and failed transitions from hospitals, EDs, & nursing homes.

Less waste

Clinical practice will be more rewarding. Happier

physicians & staff

CARE COORDINATION INFRASTRUCTURE

Address mental health and substance use stigma Integrate Peer Providers into all agencies that are part of the Partnership Team

Integrate Family Member Providers into all agencies that are part of the Partnership Team Use clinical information systems to coordinate and monitor services for individuals and populations

Measure coordination of care and outcomes

DEVELOP EFFECTIVE COLLABORATIVE CARE RELATIONSHIPS 1. Convene agencies that have a

shared aim of improving the health status of individuals

2. Define the client/patient population

3. Engage and strengthen relationships between the provider organizations convened

4. Increase knowledge of the roles peer and family member providers

5. Develop the role of the Convener Organization

6. Establish the Care Coordination Team and individual agency roles and responsibilities

7. Develop the role of the Care Coordinator

8. Build the Business Case for ongoing support of the care coordination effort

ENGAGE CLIENTS IN THEIR WHOLE HEALTH NEEDS 1. Do outreach 2. Actively engage each

client/patient in his/her Care Coordination

3. Screen clients/patients’ whole health

4. Follow up with more in-depth assessments

5. Actively engage client/patient in Care Planning

6. Actively engage client/patient in Self Mgmt.

7. Develop the roles of peers 8. Collaborate with the

client/patient/family to develop a whole health service plan

9. Promote health literacy 10. Match level/intensity of care

coordination

DELIVER COORDINATED SERVICES

1. Assign Care Coordinator to identified clients/patients

2. Make Clinical Care Managers available 3. Use a universal release of information (ROI) 4. Develop and use standard referral processes

and protocol 5. Create processes and workflows to achieve

coordinated care 6. Conduct regular multi-disciplinary meetings, 7. Require multidisciplinary team meetings 8. Perform monthly medication reconciliation 9. Care Coordinator insures clients/patients

have a single medication list 10. Design a single page Care Coordination

Service Plan

Care Coordination Collaborative Changes Seamless

experience of care that is person-centered,

cost effective,

and improves

health and wellness for individuals

and populations

1. Outreaching, engaging, and facilitating clients’ access to appropriate services

2. Defining the Care Team (including natural supports) for each client/patient

3. Ensuring and monitoring consent to share clinical information (ROI)

4. Ensuring and monitoring appropriate screening for medical, mental health and substance use conditions

5. Facilitating referrals

6. Entering clinical information into caseload registry tool

7. Conducting multidisciplinary clinical care conferences

8. Ensuring and monitoring routine medication reconciliation

9. Supporting client self-management

10. Ensuring and communicating shared care plan goals among client/patient and providers (primary care, mental health, and substance use providers)

11. Ensuring availability of ad hoc clinical case consultation

12. Ensuring urgent care access to specialty MH, SUD or primary care

13. Monitoring transitions in care

Key Care Coordination Processes

Example: Shared Care Plans-My Total Health Plan

Example: Clinical Care Coordination Meetings

Effective communication requires various kinds of meetings. Today we are focused on CC-Systematic Caseload Reviews. Here are some examples of other CC meeting types:

Table 1: Example Clinical Meeting schedule for non-co-located Integrated care teams. Pa

tor PC

Daily Medical Huddle Daily (x) x x

Systematic Caseload Review

Weekly x x x

Multidisciplinary Meeting As needed x x x MH Case Manager Family / Advocate Psychiatrist Peer Counselor SU Counselor

Return on Investment

Washington State Institute for Public Policy, 2013

Setting the stage to demonstrate integrated care capacity/readiness • Pilot Teams: groundwork for Business Case for Integrated Care –communications,

sharing data and tracking key utilization and cost measures • Readiness for 1115 Waiver Renewal and SUD Waiver

Thank You for Participating in the Care Coordination

Collaborative!

Your Progress in Integrating and Coordinating Care is Making a

Difference in the Whole Health of Our Clients and Their Families

Team Presentations!

Group One

TABLE TOP DISCUSSION: Integrating Program and Health Plan

Based Care Coordination

Marc Avery, MD University of Washington, AIMS Center

& Gale Bataille, MSW

California Institute for Behavioral Health Solutions

Organizing Care Coordination Roles across Plans and Providers

Both Health Plans and Providers are increasingly focused on providing care management/care coordination… 20 min—Table Top Discussion (Include HP if possible) 1. What are the differences in roles of the plan-based care

manager (CM) & provider care coordinator (CC)? 2. How can you eliminate redundancies/increase clarity re:

CC for both HP/providers and patients? 3. How will data client data be shared among Plan CM and

Provider CC? 20 min –Full Group Discussion

Team Presentations!

Group Two

LUNCH!

FINAL REVIEW OF CCC ASSSESSMENT: Team Assessment of Care Coordination Capacity

Jerry Langley Associates in Process Improvement

Team Assessment of Care Coordination Capacity

Care Coordination Collaborative Team Assessment of Care Coordination Capacity

COUNTY PARTNERSHIP TEAM: _______________ Instructions:

1. Each team should complete this assessment and submit only one completed survey. 2. At a CCC partnership team meeting, review questions and discuss. Allow each partner to score based on their perspective. 3. The column “How is it coordinated?” is not applicable to each survey question. If not applicable, “put NA” 4. Please complete electronically and submit your survey no later than January 9, 2015

SCORING: 0 = not ever; 1 = not yet; 2 = we’re talking about it; 3 = in testing; 4 = implemented

CARE COORDINATION TASKS

PC MH SUD Health Plan How is it coordinated?

ROLE/TITLE

DEVELOP EFFECTIVE COLLABORATIVE CARE RELATIONSHIPS

Share about each other’s common core values, capacity, assets, limitations, funding sources, and service gaps to identify opportunities to create care coordination

Include the views and priorities of the people affected by the partnership’s work

Team Assessment of Care Coordination Capacity CARE COORDINATION TASKS

ROLE/TITLE

IDENTIFY AND ENGAGE CLIENTS (PATIENTS)

DELIVER COORDINATED SERVICES

ENGAGE CLIENTS IN THEIR WHOLE HEALTH NEEDS

TRACK SERVICE COORDINATION AND TREATMENT OUTCOMES & ADJUST TREATMENT IF CLIENTS ARE NOT RESPONDING

Team Assessment of Care Coordination Capacity CARE COORDINATION TASKS

ROLE/TITLE

Share about each other’s common core values, capacity, assets, limitations, funding sources, and service gaps to identify opportunities to create care coordination

Include the views and priorities of the people affected by the partnership’s work

Establish the care coordination team and individual agency roles and responsibilities, including designation of a sponsor within each agency for care coordination improvement

Build a business case that demonstrates the care coordination efforts improve quality of care and outcomes, while reducing costs

Team PC MH SU HP CCS 2.3 / XX 3.6 / XX 3.5 / XX 3. 0 / XX Fresno 3.1 / 2.4 3.3 / 3.8 XX / XX XX / 3.0 Mendocino XX / 2.4 XX / 2.9 XX / 2.1 XX / 3.1 Inyo 2.5 / 3.1 2.7. / 3.1 2.3 / 3.1 1.0 / XX Lake 2.0 / 2.4 2.3 / 2.1 2.2 / 1.3 XX / 1.5 Madera 1.9 / XX 2.0 / XX 1.6 / XX 1.7 / XX Modoc 2.3 / 2.2 2.2 / 2.9 1.8 / 2.7 XX / 1.7 RENEW XX / 2.9 2.6. / 3.9 XX / 2.0 XX / 0.1 Solano 2.8 / 3.8 2.7 / 3.8 1.9 / 3.3 2.4 / 4.0 Tuolumne 2.5 / 3.6 2.5 / 3.6 1.7 / XX 1.0 / 3.0

Legend

CCS Fresno Mendo. Inyo Lake Madera Modoc RENEW Solano Tuol. PC

February, 2014 January, 2015

Legend

Questions?

Team Presentations!

Group Three

Teams Acknowledgment!

Thank You for Participating

in the Care Coordination Collaborative!

Your work truly makes a difference!

Care Coordination Collaborative Learning Session #5...The Impact of Co-Occurring Conditions...

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