Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
Care Coordination Collaborative Learning Session #5
Wednesday January 21st , 2015
Welcome! • Introductions • Agenda Overview
2
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
10:45-12:00 3 Team Presentations
12:00-1:00 LUNCH
1:00-2:15 Final Review of CCC Assessment
2:15-2:30 BREAK
2:30-3:45 3 Team Presentations
3:45-4:45 Teams Acknowledgment/Celebration
4:45-5:00 A Look at Day 2 and Adjourn
3
4
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?
9
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
Cost
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
tient
/
Cons
umer
Ca
re
Coor
dina
tor PC
P
Nur
se
Med
ical
Co
nsul
tant
Psyc
hiat
ric
Cons
ulta
nt
Oth
ers
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
DDD
Return on Investment
Cost
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
14
Team Presentations!
16
Group One
17
Team
1.
2.
3.
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
18
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
BREAK
20
Team Presentations!
21
Group Two
22
Team
1.
2.
3.
LUNCH!
23
FINAL REVIEW OF CCC ASSSESSMENT: Team Assessment of Care Coordination Capacity
Jerry Langley Associates in Process Improvement
24
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?
NAME
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
PC MH SUD Health Plan How is it coordinated?
NAME
ROLE/TITLE
DEVELOP EFFECTIVE COLLABORATIVE CARE RELATIONSHIPS
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
PC MH SUD Health Plan How is it coordinated?
NAME
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
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
SCORING: 0 = not ever; 1 = not yet; 2 = we’re talking about it; 3 = in testing; 4 = implemented
Team Assessment of Care Coordination Capacity
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
Team Assessment of Care Coordination Capacity
Legend
CCS Fresno Mendo. Inyo Lake Madera Modoc RENEW Solano Tuol. PC
MH
SU
HP
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
SCORING: 0 = not ever; 1 = not yet; 2 = we’re talking about it; 3 = in testing; 4 = implemented
February, 2014 January, 2015
Team Assessment of Care Coordination Capacity
Legend
CCS Fresno Mendo. Inyo Lake Madera Modoc RENEW Solano Tuol. PC
MH
SU
HP
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
SCORING: 0 = not ever; 1 = not yet; 2 = we’re talking about it; 3 = in testing; 4 = implemented
February, 2014 January, 2015
Team Assessment of Care Coordination Capacity
Legend
CCS Fresno Mendo. Inyo Lake Madera Modoc RENEW Solano Tuol. PC
MH
SU
HP
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
SCORING: 0 = not ever; 1 = not yet; 2 = we’re talking about it; 3 = in testing; 4 = implemented
February, 2014 January, 2015
Team Assessment of Care Coordination Capacity
Legend
CCS Fresno Mendo. Inyo Lake Madera Modoc RENEW Solano Tuol. PC
MH
SU
HP
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
SCORING: 0 = not ever; 1 = not yet; 2 = we’re talking about it; 3 = in testing; 4 = implemented
February, 2014 January, 2015
Team Assessment of Care Coordination Capacity
Legend
CCS Fresno Mendo. Inyo Lake Madera Modoc RENEW Solano Tuol. PC
MH
SU
HP
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
01234
SCORING: 0 = not ever; 1 = not yet; 2 = we’re talking about it; 3 = in testing; 4 = implemented
February, 2014 January, 2015
Questions?
BREAK
35
Team Presentations!
36
Group Three
37
Team
1.
2.
3.
Teams Acknowledgment!
38
Thank You for Participating
in the Care Coordination Collaborative!
Your work truly makes a difference!
39