Community Care Coordination Scorecard—

Raising the Bar for Measuring Improvements

in Access to Care Across

Communities

Sherry E. Gray, DirectorRural and Urban Access to Health-St. Vincent Health

Building and supporting community capacity: Measuring the Success and Barriers

to Medical Home Placement for Our Most Vulnerable Community Members

AHRQ 2010 Annual ConferenceMonday, September 27, 2010

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WHO is RUAH*?

*What does it mean? The word ruah, in yiddish means “Breath of Life”. The Goal? …to breathe new life into a health care system that serves our most vulnerable community

members

10 Health Access Workers (HAW) in 8 communitiesHospital associates: community focused

7 Medication Access Coordinators (MAC)Hospital and Community Agency Associates

System Administrative Support : Health Access Manager; Operations Facilitator; Language Access Staff; System Director

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What is the Work of RUAH?

Client Advocacy and System Navigation via Health Access Workers Pharmacy Assistance – access to low or no cost drugs connecting

through Medication Access Coordinators (MAC’s) Creation of “Medical Homes” for the underserved Access to Specialty Care for the underserved Program enrollment (financial resource review and application

assistance: public AND private) Reduction of inappropriate Emergency Room utilization Reduction of hospital re-admissions for chronic diseases Assistance with supportive social services (“wrap around”) Outcome Based Measurement

– Pathway Model– Community Care Coordination: “Hub”

Language Access – Medical interpretation and translation of vital documents

System Change

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Why?

To provide & increase access for uninsured/underinsured community members: Right Care Right Time Right Place Right Provider Right Payer

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So That…

Un/underinsured community members can receive care “sooner vs. later” Consistent and familiar care is provided along with follow up & follow through:

treatment is across time and not episodic Resources are used as effectively as possible, including:

– Human Providers, Practitioners, Care Coordinators, Administrative support, etc.

– Financial Reimbursement, Funding, Cost-Avoidance, “Write-Off’s”

– Technological Connecting Information in a timely, meaningful way

– Support (wrap-a-round) Services Connecting medical treatment, public health practices, & psychosocial principles

Vital connections are made– Integrate and coordinate care not duplicate and replicate care– “Best Practice” Learning's are shared; and solutions are not “re-created”

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How RUAH got HERE:

Realization: increased access, services provided, and reimbursement was intuitively a “good thing”, but proved NOTHING!

Resolved to find out if a positive difference was made in the lives of those we are seeking to serve. If so, how could that be demonstrated and or verified? If not, what needed to change?

Researched Best Practice models in OUTCOME MEASUREMENT, specific to community care coordination.

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One thing leads to another…

Community Care Coordination Learning Network

-Learned about Pathways; -Began building a Community HUB

-Invited to be part of the Innovations Exchange: AHRQ

Joined the CCCLN:-Hub Manual Development

-Outcome Measure Scorecard Project

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Program & Community Benefits

Best Practices are shared There’s no “charge” for advice/consultation Moves individual, community programs out of an

isolated vacuum Increases credibility Creates momentum Improves chances of sustainability Demonstrates that in the healthcare delivery system

change can and does happen

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Challenges

Balance between differences & similarities for each community involved

– How to design a structure that also respects the inherent need for flexibility?

– How to explain, define, communicate the structure?

Outcome Measurement– Agreed upon

Definitions? Operations/Practices? Parameters? Reporting Structure?

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Lessons Learned

There’s a reason most communities don’t gravitate to this work

The work has to be communicated in different ways for different audiences and stakeholders

Integration and coordination of care goes against the grain of how the health system has evolved

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Scorecard group formed through the Community Care Coordination Learning Network– Initiatives/measures developed– RUAH data submission initiated Spring, 2010

Developed the Required Data Points for the Medical Home Scorecard Measure, for all participants

Medical Home: Assessing the Effectiveness of Access Initiatives

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Required Data Points for the Medical Home Scorecard Measure=

Clients’ demographic data during 1 month time frame Insurance Status Source of Ongoing primary care

– Was a referral started to achieve an ongoing source of primary care?

Barriers to completing that referral Date the connection to ongoing primary care was made Supportive (“wrap around”) social service referrals:

– Barriers– Date connection was made to resolve identified social service

need

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Where RUAH is at in the Process:

Able to submit most of the required data

Beginning stages of implementing Pathways– RUAH = Eight different communities– Piloting Pathways in one site currently = sole data reporting community – Challenge: reporting outcomes for ongoing source of primary care and social

service referrals

Participation in the Scorecard Measure process is accelerating the goal of appointment verification and follow-up coordination and verification.

Adopting the Pathways model = Report on outcomes vs. counting referrals/activities

Adds accountability, credibility and rationale for system change and sustainability

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So What “Gains” Have been Made?

Five Pathways have been developed for the Anderson Site– Medical Home

CCCLN Scorecard Measure Project Also

– Pregnancy Care– Childhood Immunizations– Government Funded Program Enrollment– Government Funded Program Re-Enrollment

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Now What?

Agreements for HUB being signed Common ROI developed for HUB members Common Care Coordination “check in” line

developed to start a Pathway Process being implemented for monthly

Pathway process checks and outcome measurement

We’ll be able to tell you next year!