Best Practices in Care CoordinationBest Practices in Care Coordination

Edward L. Schor, MD,Lucile Packard Foundation for Children’s Health

CCS Plus Care Coordination SummitCCS Plus Care Coordination SummitJune 8, 2012

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Triple Aim Goals and Some ApproachesTriple Aim Goals and Some Approaches

• Improving the experience of careImproving the experience of care– Care planning and implementation– Receipt of recommended servicesp– Informed decision‐making

• Improving the health of populationsImproving the health of populations– Life course perspective– Prevention and health promotionp

• Reducing per capita costs of health care– Appropriate use of servicesAppropriate use of services– Efficient systems of care

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What is Care Coordination?What is Care Coordination?

“Care coordination occurs when care plans are pimplemented by a variety of service providers and programs in an organized fashion.” – AAP 

il hild i h i bili iCouncil on Children with Disabilities

“Pediatric care coordination is a patient andPediatric care coordination is a patient and family‐centered, assessment‐driven, team‐based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families.” – Antonelli, McAllister & P

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Popp

Essential Elements of Quality Comprehensive Care CoordinationComprehensive Care Coordination

• Accessible, including community‐based• Qualified care coordinator• Intake screening• Comprehensive assessment• Comprehensive assessment• Develop a care or service plan• Family/patient‐centered goal setting, planning and servicesFamily/patient centered goal setting, planning and services• Services: Inform, arrange and/or provide services (includes 

advocacy and financing)T i / f i f i i id• Transmit/transfer information among service providers

• Monitor service delivery• Ongoing reassessmentOngoing reassessment• Ongoing relationship between client and care coordinator (ideal)

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Delivering Care CoordinationDelivering Care Coordination

Assessment

Goal SettingContinuous Monitoring 

Goal Setting& Improvement

Care Planning and Facilitation

5Modified from:  Antonelli RC, McAllister JW, Popp J.  Making Care Coordination a Critical Component of the Pediatric Health System.  The Commonwealth Fund. May 2009

Distribution of Children By Chronic Illness C tCategory

Population Cost

0.06% 2.36%

M t t ti0.01% 0.64%

0 10% 1 68%Life Long Progressive 

Metastatic Malignancy

0.10% 1.68%

2.45% 12.65%Life Long Progressive

Technology Dependent

5% 65%

12.30% 26.44%Episodic Chronic

Life Long Chronic

85.1% 56.2%Non‐Chronic

Source:  J. Neff, Treo‐CRG 6

Care Coordination in Pediatric PracticesCare Coordination in Pediatric Practices

Keep List ofDesignated Care Keep List of Community Service

Providers57%

Designated Care Coordinator

81%39%

16%16%

Yes NoYes No

Commonwealth Fund IHP Survey 2009

Pediatric Practice Creates Written C Pl f CYSHCNCare Plans for CYSHCN

45%

33%

45%

33%

17%

3%

Often Sometimes Rarely NeverOften Sometimes Rarely Never

The Commonwealth Fund, IHP Survey, 2009 8

Pediatric Practices Receiving Payment for C C di tiCare Coordination

86%86%

9%1%

9%

All Payers Some Payers None

The Commonwealth Fund, IHP Survey, 2009 9

Care Coordination in Pediatric Primary Care P tiPractices

No Psychosocial Issues Psychosocial Issues*

Non‐CSHCN 9.4 minutes(clinical and referral 

t d

14.1 minutes(mental health, legal and 

i l i )management and education)

social services)

CSHCN 17.6 minutes 19.3 minutes(mental health legal and(mental health, legal, and social services)

Costs ranged from $4 39 to $12 86 per CC encounter; average $7 78Costs ranged from $4.39 to $12.86 per CC encounter; average $7.78

Source:  Antonelli RC, Stille CJ, Antonelli DM.  Care Coordination for CYSHCN.  Pediatrics 2008; 122(1):e209‐e216

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Improving Linkage: 3 Levels of StrategiesImproving Linkage: 3 Levels of Strategies

1. Practice‐level systems change

2. Community partnerships

h3. Community systems change

11Source:  Fine & Mayer.  Beyond Referral.  The Commonwealth Fund, December 2006

Organizational Options for Care CoordinationOrganizational Options for Care CoordinationKey question:  Point of Entry & Point of Service:  Single Vs Multiple?

• Referral coordinator in practice or agency• Care Coordinator in practice or agency

Offi b d d b i l i• Office‐based supported by regional entity• Care coordinator shared among practices or agencies

Private arrangement– Private arrangement– Health care organization – Public agency

• Regional resource providing facilitation and support– Telehealth models:  Help Me Grow; Massachusetts Child 

Psychiatry Access ProjectPsychiatry Access Project– eReferral models:  SF General; Doc2Doc

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Mechanisms for Providing Care CoordinationMechanisms for Providing Care Coordination

• Individual care coordinator• Care coordination team• Face‐to‐face with client

C t t ith h i i (f t f th )• Contact with physician (face‐to‐face or other)• Various e‐care options:

– TelephoneTelephone– Email– Messaging devices– Digital photos– Video

• Relationship‐based among providers and organizations

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Local Policies to Facilitate Care CoordinationLocal Policies to Facilitate Care Coordination

R f l d F db k S t• Referral and Feedback Systems

• Interagency AgreementsInteragency Agreements

– Accountability

– Standardized forms and processes

– Privacy policies (HIPAA FERPA IDEA)Privacy policies (HIPAA, FERPA, IDEA)

• Data Sharing Agreements

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Structural Factors that Support High Quality Care CoordinationQuality Care Coordination

• Interdisciplinary advisory committeeInterdisciplinary advisory committee

• Parent advisory committee to practices

• Ongoing quality improvementOngoing quality improvement

• Adequate reimbursement

• Incentives for quality• Incentives for quality

• Clear standards and quality measures

H l h I f i h l• Health Information technology

• Interagency collaboration in community or state

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Shared Resources: OutsourcingShared Resources: Outsourcing

PrimaryCare Primary

CareCC CC CareCC

CC

CC

PrimaryCare

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Community Care of North Carolina: MedicaidCarolina: Medicaid

Asthma Initiative: Pediatric Asthma Hospitalization rates 

(April 2000 – December 2002) • 14 networks, > 3,200 MDs, >800,000 patients( p )

In patient admission rate per 1000 member months

14 networks,   3,200 MDs,  800,000 patients

• $3 PMPM to each network

• Hire case managers/medical management staff

• $2.50 PMPM to each PCP to serve as medical home and

789

$2.50 PMPM to each PCP to serve as medical home and participate in disease management

• Care improvement: asthma, diabetes, screening/referral of young children for developmental problems, and more!

3456

more!

• Case management: identify and facilitate management of costly patients 

• Cost savings analysis (per Mercer):

012

Access I Access II & III

– FY2003: $60 million– FY2004: $124 million– FY2005: $77‐85 million– FY2006: $154‐170 million

17Source: L. Allen Dobson, MD, presentation to ERISA Industry Committee, Washington, DC, March 12, 2007

FY2006: $154 170 million

Vermont Blueprint for Health Sharing Resources to Integrate CareSharing Resources to Integrate Care

& Control Costs

Hospitals

Community Care Team

CommunityPractice

CommunityP iCommunity Care Team

Nurse CoordinatorSocial Workers

DieticiansCommunity Health Workers

Mental Health & Substance Use Disorders

Practice

CommunityPracticeCommunity Health Workers

Care CoordinatorsPublic Health Prevention Specialist

Public Health

Practice

CommunityPracticePractice

18HIT Global Information Evaluation Operations

Cost SavingsCost Savings

• Adult practices with high proportion of chronicallyAdult practices with high proportion of chronicallyill patients are able to save money

• Direct interaction with the physicians and significant in‐person interaction with patients increased possibility of cost savings

• Pediatric practices with low proportion of chronically ill patients have not documented cost savings

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Paying for Case Management and Care dCoordination

• Targeted Case Management• Targeted Case Management

• CPT Codes for Multi‐Disciplinary Care Coordination

• Capitated Payment:  Per Member Per Month Fees

– Risk adjusted (biologic and social)

– Tiered based on complexity and time

• Pay for Performancey

• Medical Homes Certification Bonuses

• Health Homes enhanced federal matchHealth Homes enhanced federal match

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Evaluating Care CoordinationEvaluating Care Coordination

Access Quality Cost

Structure

Process

Outcome

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Centrality of FamiliesCentrality of Families

“The health and well‐being of children are 

inextricably linked to their parents’ physical, 

emotional and social health socialemotional and social health, social 

circumstances, and child‐rearing practices.”

22Source:  AAP Task Force on the Family.  Family Pediatrics.  Pediatrics, June 2003

ResourcesResources• Antonelli RC, McAllister JW, Popp J.  Making Care Coordination A Critical Component of the

Pediatric Health System: A Multidisciplinary Framework.  The Commonwealth Fund.  May 2009. (www.cmwf.org) 

• Fine A, Mayer R.  Beyond Referral: Pediatric Care Linkages to Improve Developmental Health.  The Commonwealth Fund. December 2006. (www.cmwf.org) 

• Henderson M, Kaye N.  Policies for Care Coordination Across Systems:  Lessons from ABCD III. N ti l A d f St t H lth P li M 2012 ( h )National Academy for State Health Policy.  May, 2012.  (www.nashp.org)

• O’Malley AS, Tynan A, Cohen GR, Kemper N, Davis MM.  Coordination of Care by Primary Care Practices: Strategies, Lessons and Implications.  Center for Studying Health System Change.  Research Brief No. 12, April, 2009

• Reducing Care Fragmentation: A Toolkit for Coordinating Care. The MacColl Center for Health Care Innovation at the Group Health Research Institute, Seattle Washington. http://www.improvingchroniccare.org/index.php?p=Care_Coordination&s=326

• Rosenbaum S Johnson K Jones E and Markus A Medicaid and Case Management to PromoteRosenbaum S, Johnson K, Jones E and Markus A.  Medicaid and Case Management to Promote Health Child Development. George Washington University School of Public Health and Health Services for The Commonwealth Fund, 2009                                                  

http://www.gwumc.edu/sphhs/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_FB044708‐5056‐9D20‐3D1C4A53DFA85EC7.pdf

• Wise PH, Huffman LC, Brat G.  A Critical Analysis of Care Coordination Strategies for Children with Special Health Care Needs. AHRQ Publication No. 07‐0054, June 2007

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