PCMH LEARNING COLLABORATIVE: CARE COORDINATION JULY 19, 2017

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1 PCMH LEARNING COLLABORATIVE: CARE COORDINATION JULY 19, 2017

2 AGENDA Overview of Care Coordination PCMH 2014 Standard 5: Care Coordination and Care Transitions Collaborative Care: An Application of Care Coordination 2

3 Care Coordination helps ensure that the patient s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high quality patient experiences and improved healthcare outcomes. the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Source: National Quality Forum, NQF-Endorsed Definition and Framework for Measuring Care Coordination & care/improve/coordination/atlas2014/chapter2.html 3

4 Goals of Care Coordination Reduce fragmentation of care Help patients access timely, appropriate care Help patients more fully engage in their care and self-manage their health better Reduce health disparities/inequities Address social determinants of health 4

5 Care Coordination Focuses On Patients and their families Help them access care and overcome barriers to quality care Providers Coordinate interactions between providers which will help patients have better continuity of care Systems Ensure that systems are in place to facilitate coordinated care and sharing of information about all aspects of a patient s care 5

6 Other Care Models Related to Care Coordination Team-based care Continuity of care Disease management Case management Chronic care model Care navigation or patient navigation Source: Closing the Gap: A Critical Analysis of Quality Improvement Strategies. Agency for Healthcare Research and Quality, US Department of Health and Human Services, June 2007, p

7 Typical Care Coordination Services Offer patient education materials in several languages Assist patients in filling out forms Identify financial aid options Help arrange patient transportation as needed Maintain regular contact with patients during their care Coordinate services within the healthcare organization, with outside healthcare facilities, and within the community Guide patients through the healthcare system Help patients arrive at scheduled appointments on time and prepared Identify barriers to care Ensure that abnormal screenings are followed up Link patients, caregivers, and their families with needed follow up services Increase access to culturally appropriate, supportive care 7

8 Care Transition Movements of patients from one care setting to another Can be an extremely vulnerable time for patients and their caregivers Unique vulnerabilities for patients with multiple chronic conditions, mental illness, substance use disorders, or elderly 8

9 Different types of care transitions Hospital to home to primary care provider Hospital to nursing home or rehab facility Primary care provider to specialist Primary care provider to hospital Community based organization to primary care provider 9

10 Transitions of Care: Statistics Poor care coordination increases the chance that a patient will suffer from a medication error or other health care mistake by 140 percent. Communication failures between providers contribute to nearly 70 percent of medical errors and adverse events in health care. Uninsured patients or those with Medicare or Medicaid are 60 percent more likely than those with private insurance to go to the ED for follow-up care instead of a PCP or outpatient clinic. Getting to Impact: Harnessing health information technology to support improved care coordination December Coordination-Part-I_Final_ pdf 10

11 Transitions of Care: Statistics 17% of adults hospitalized in previous two years reported that information about their care had not been communicated to them 27% said the hospital made no arrangements for follow-up visit in primary care 67% who were given a new prescription were not told whether to take their other medications 48% reported receiving no information on medication side effects Taking the Pulse of Healthcare Systems: Experiences of Patients with Health Problems in Six Countries. Health Affairs Web Exclusive, November 3, 2005, W

12 Transitions of Care: Statistics Centers for Medicare and Medicaid Services (CMS) Data states: 19% of patients had identifiable adverse events in the first 3 weeks home. 73% of older patients misused at least one medication. AHRQ: Data on Adult Care Transitions:

13 Best Practices around Care Transitions: Four key Areas to Focus on Patient/Family Engagement and Activation Medication Management Comprehensive Transition Planning Care Transition Support 13

14 Patient/Caregiver Engagement and Activation Typical Challenges Self-care Unrealistic optimism of patient and family to manage at home Multiple drugs exceed patient s ability to manage Care Planning Failure to include patient and care givers Lack of understanding of patient s physical and cognitive functional health status Multiple providers; patient believes someone is in charge 14

15 Patient/Family Engagement and Activation: Best Practices Self-care Assessment is conducted of patient/caregiver s ability to provide self-care after discharge Post-discharge telephone care management Care Planning Work with patient/ caregivers to prepare for post discharge visit (goals, questions, concerns) Health Literacy Embed health literacy principles into all patient education and materials Provide culturally and linguistically appropriate care 15

16 Medication Management Typical Challenges Oversight of Medication List Medication list is incorrect No care provider assigned accountability of the patient s medications Communication Lack of communication with providers across the continuum of care Patient/Caregiver engagement Understanding of patient s ability to take medication not assessed Patient does not have resources to obtain medication after discharge 16

17 Medication Management Best Practices Assess Knowledge Medication List Bring in Pharmacists Assess patient s knowledge of medications, include Teach Back and include this information in care plan A written list of medications is provided to the patient and family including name, dose, route, purpose, side effects and special considerations For patients with complicated medication regimes, pharmacy may perform patient education, medication review, follow up phone calls 17

18 Comprehensive Discharge Planning Typical Challenges Discharge Plan Content Written discharge instructions confusing, contradictory, hard to understand Lack of an emergency plan, who the patient should call first, lack of understanding of red flags Care Coordination Lack of coordination and information sharing between facility and community care providers including primary care Patient returns home without essential equipment (scale, supplemental oxygen) 18

19 Comprehensive Discharge Planning Best Practices Discharge Planning Process Connect with the patient/family/caregiver while they are still in the hospital to prepare for post discharge visit planning Modify written discharge plan to include (in plain language) Reason for hospitalization Medications to be taken post discharge Self-care activities such as diet and activity Supplies needed and where to obtain them Symptom recognition and management-who to contact and how to contact them if needed Coordination and planning for follow up appointments Community resources patient will utilize such as Meals on Wheels, home health care, physical therapy, etc. 19

20 Transition Care Support Typical Challenges No follow up appointment scheduled Follow up with provider too long after hospitalization Follow up is seen as sole responsibility of patient Patient unable to keep follow up appointments because of transportation issues Multiple care providers; patient believes someone is in charge 20

21 Transition Care Support Best Practices Assess the patient s understanding of the discharge plan by asking them to explain the details of the plan in their own words Assign accountability for patient issues between hospitalization and next provider visit, and inform the patient who is in charge of their care and how to contact them Provide telephone reinforcement of the plan 2-3 days after discharge Establish relationships with local hospitals to receive admission and discharge information Join Regional Health Information Organization (RHIO) and pull information regarding recent hospitalizations Provide or arrange for a coach for a pre-discharge hospital visit, home visit and follow up telephone calls 21

22 Care Coordination in Patient-Centered Medical Home Identify patients who would benefit from more rigorous care coordination Comprehensive Assessment Person-Centered Care Plan Self-Management Support and Education Coordinate Care Transitions Follow up on Lab Work and Imaging Follow up and track Referrals 22

23 PCMH 2014 STANDARD 5: CARE COORDINATION AND CARE TRANSITIONS

24 Agenda PCMH 2014 Standard 5 Care Coordination and Care Transitions A. Test Tracking and Follow- Up B. Referral Tracking and Follow-Up C. Coordinate Care Transitions 24

25 PCMH 5A Test tracking and follow-up

26 PCMH 5A: Test Tracking and Follow-Up Element A: Test Tracking and Follow-Up 6.00 points The practice has a documented process for and demonstrates that it: Yes No NA 1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR) 3. Flags abnormal lab results, bringing them to the attention of the clinician. 4. Flags abnormal imaging results, bringing them to the attention of the clinician. 5. Notifies patients/families of normal and abnormal lab and imaging test results. 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (NA for adults). 7. More than 30 percent of laboratory orders are electronically recorded in the patient record. 8. More than 30 percent of radiology orders are electronically recorded in the patient record. 9. Electronically incorporates more than 55 percent of all clinical lab test results into structured fields in medical record. 10. More than 10 percent of scans and tests that result in an image are accessible electronically. Scoring 100% 75% 50% 25% 0% The practice The practice The practice meets 6-7 meets 4-5 meets 3 factors factors factors (including (including (including factors 1 factors 1 factors 1 and 2) and 2) and 2) The practice meets 8-10 factors (including factors 1 and 2) The practice meets 0-2 factors (or does not meet factors 1 and 2) 26

27 Documentation 5A Factors 1-6 Factor 7 Factor 8 Process for tracking lab and imaging tests, including flagging, following up, and contacting patients about results Report or log showing the tracking Examples of how the process is met for each factor Report showing the percent of laboratory orders that are electronically recorded *MU report Percentage should be calculated using the following methodology: Denominator = Number of lab tests ordered during the reporting period (at least 3 months) Numerator = Number of lab tests ordered that are electronically recorded in the patient record *NA response applicable if practice orders fewer than 100 lab orders during the reporting period Report showing the percent of radiology orders that are electronically recorded *MU report Percentage should be calculated using the following methodology: Denominator = Number of radiology tests ordered during the reporting period (at least 3 months) Numerator = Number of radiology tests ordered that are electronically recorded in the patient record *NA response applicable if practice orders fewer than 100 radiology orders during the reporting period 27

28 Documentation 5A Factor 9 Factor 10 Screenshot showing capability or Report showing the percent of lab tests electronically incorporated into structure fields in the EMR Percentage should be calculated using the following methodology: Denominator = Number of lab tests ordered during the reporting period (at least 3 months) with results expressed in positive or negative affirmation or as a number Numerator = Number of radiology tests ordered whose results are expressed in positive or negative affirmation or as a number which are incorporated as structured data *NA response with written explanation is applicable if practice orders no lab test whose results are in a positive or negative affirmation or numeric format during the reporting period. Screenshot showing capability Report showing the percent of scans and tests with images that are viewable in the EMR *MU report **PDF images scanned into the EMR count for this factor Percentage should be calculated using the following methodology: Denominator = Number of tests whose result is one or more images ordered during the reporting period (at least 3 months) Numerator = Number of results in the denominator that are accessible in the practice electronic system *NA response with written explanation is applicable if practice orders less than 100 tests during the reporting period whose result is an image or who has no access to electronic imaging results at the start of the reporting period

29 PCMH 5A Factor 1 Our practice has an in house lab that s interfaced w/ our EMR. All labs are tracked until resulted. Screenshot displays how lab techs can view all labs ordered and received/resulted Written process or policy must be a dated document at least 90 days prior to submission. Report: Screenshot from EMR 29

30 PCMH 5A Factor 2 30

31 PCMH 5A Factor 3 and 4 31

32 PCMH 5A Factor 5 Our practice has a policy to contact patients in order to inform them of all test results. Below is an example of a lab result Will need to show both test and imaging results, normal and abnormal examples

33 PCMH 5A Factor 6 Newborn Hearing and Blood Spot Screening

34 PCMH 5A Factor

35 PCMH 5A Factor 10 Screenshot Showing Image Accessible Electronically Scanned PDF of image also Counts!

36 PCMH 5B Referral tracking and follow-up (Must Pass)

37 PCMH 5B: Referral Tracking and Follow-Up (MUST PASS) 37

38 Documentation 5B Factors 1 Factor 2 & 3 Factor 4 Factor 5-6, 8, & 10 Factor 7 Factor 9 Examples of the type of information the practice team has available on specialist performance Examples, at least one collaborative agreement for each factor Materials that explain how behavioral health is integrated with physical health Process which covers each factor Report, Log, or other demonstrating that the process is followed; Log may be a paper log or a screen shot showing electronic capabilities Report may be system generated or may be based on at least one week of referrals Examples, at least three demonstrating practice asks patient about self-referrals Report from the electronic system Percentage should be calculated using the following methodology: Denominator = Number of transitions of care and referrals (at least 3 months) Numerator = Number of transitions of care and referrals in the denominator where a summary of care record is provided electronically Examples, at least three demonstrating co-management between the pcp and specialty provider 38

39 PCMH 5B Factor 1 39

40 PCMH 5B Factor 2 Formal and Informal Agreements with Specialists 40

41 PCMH 5B Factor 3 Maintains Formal Agreements with Behavioral Health Providers 41

42 PCMH 5B Factor 4 Integrating BH into the Practice (1 of 5) 42

43 PCMH 5B Factor 4 Integrating BH into the Practice (2 of 5) 43

44 PCMH 5B Factor 4 Integrating BH into the Practice (3 of 5) 44

45 PCMH 5B Factor 4 Integrating BH into the Practice (4 of 5) 45

46 PCMH 5B Factor 4 Integrating BH into the Practice (5 of 5) 46

47 PCMH 5B Factor 5 In our practice we execute all of our referrals via the referral module. The module allows us to enter Dx codes describing the clinical question, designate the type of referral and the required timing. Type of referral Required timing Clinical question 47

48 PCMH 5B Factor 5 continued Clinical Question: Additional Information Referral note to the specialist from the PCP 48

49 PCMH 5B Factor 6 NCQA is looking for current meds, Dx, Reason for referral, clinical findings & current Tx, follow-up communication or information, Pt Demographics i.e., language, DOB, Sex, Contact info, Ins. Info But wait there s more

50 PCMH 5B Factor 6 continued Additional Items 50

51 PCMH 5B Factor 7 Summary of Care or CCDA 51

52 PCMH 5B Factor 7 Summary of Care Report (50) (50) The practice must demonstrate the capability to exchange key clinical info for more than 50% of care transitions

53 PCMH 5B Factor 8 Policy PCMH 5B Factor 5,6 Tracking of overdue referrals PCMH 5B Factor 8 53

54 PCMH 5B Factor 8 Follow-up of over due reports 54

55 PCMH 5B Factor 9 Document Co-Management 55

56 PCMH 5B Factor 9 Cont d 56

57 PCMH 5B Factor 9 Referral Request including request for co-management with Specialist (5B9) 57

58 PCMH 5B Factor 10 58

59 PCMH 5C Coordinate Care Transitions

60 PCMH 5C: Coordinate Care Transitions Element C: Coordinate Care Transitions 6.00 points The practice: Yes No NA 1. Proactively identifies patients with unplanned hospital admissions and emergency department visits. 2. Shares clinical information with admitting hospitals and emergency departments. 3. Consistently obtains patient discharge summaries from the hospital and other facilities. 4. Proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit. 5. Exchanges patient information with the hospital during a patient s hospitalization. 6. Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners. 7. Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 50 percent of patient transitions of care. Scoring Explanation 100% 75% 50% 25% 0% The practice The practice The practice meets 5-6 meets 3-4 meets 1-2 factors factors factors The practice meets all 7 factors + Stage 2 Core Meaningful Use Requirement The practice meets 0 factors

61 Documentation 5C Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 Factor 7 Process for identifying patients who have been hospitalized or have had an ER visit Log of patients receiving care from different types of facilities or a report listing patients seen in the ER or hospital. Process for providing hospitals and ERs with clinical information, Examples, at least three of patient information sent to the hospital or ER Process for obtaining hospital discharge summaries, Examples, at least three discharge summaries Process for obtaining proactively contacting patients for appropriate follow up care, and reviews at least Examples, at least three screenshots of follow up with patients to schedule post ER office visit Process for two-way communication with hospitals Example, at least one showing communication, referral, discharge summary and include telephone encounter if possible Process for obtaining proper consent for release of information Report illustrating electronic information exchange or a Screen shot showing a test of capability, Report with numerator, denominator and percentage from at least three months of transitions. 61

62 PCMH 5C Factor 1 Hospital/ER Log 62

63 PCMH 5C Factor 2 Practice Shares Clinical Information with ER/Hospital (1 of 3) 63

64 PCMH 5C Factor 2 Practice Shares Clinical Information with ER/Hospital (2 of 3) 64

65 PCMH 5C Factor 2 Practice Shares Clinical Information with ER/Hospital (3 of 3) 65

66 PCMH 5C Factor 3 Discharge Summary

67 PCMH 5C Factor 4 Follow Up After ER/Hospital (1 of 2) 67

68 PCMH 5C Factor 4 Follow Up After ER/Hospital (2 of 2) 68

69 PCMH 5C - Factor 5 A Memo to the staff is also a documented process NCQA reviews the practice s documented process for two-way communication with hospitals, and reviews an example of two-way communication

70 PCMH 5C Factor 5 Hospital Request for Information Letter 70

71 PCMH 5C Factor 5 Exchange Patient Information with Hospital (1 of 3) 71

72 PCMH 5C Factor 5 Exchange Patient Information with Hospital (2 of 3) 72

73 PCMH 5C Factor 5 Exchange Patient Information with Hospital (3 of 3) 73

74 PCMH 5C Factor 6 Consent for Release of Information

75 PCMH 5C Factor 7 CCD sent Electronically 75

76 PCMH 5C Factor 7 Summary of Care sent Electronically Report 10% 76

77 Wrap Up We ve covered a lot of information today, but the main takeaway is that PCMH transformation is a process PCMH is built on many small steps that help guide a practice toward performing in a more coordinated way to provide care and manage care transitions For additional support, please contact your assigned practice transformation coach/ta vendor 77

78 COLLABORATIVE CARE AND THE MENTAL HEALTH SERVICE CORPS AN APPLICATION OF CARE COORDINATION

79 Mental Health Service Corps (MHSC) Overview Program Goals Close treatment gap by placing behavioral health clinicians in high-need areas Strengthen and expand behavioral health care workforce by training early career clinicians and placing them in practices across New York City Implement the Collaborative Care Model within primary care practices Count of Year 2 Sites by Borough Count of Primary Care Sites by Org Type Queens Brooklyn Staten Island Manhattan Bronx Small Practice Community Health Center Hospital Total

80 Mental Health Service Corps Program Alignment MACRA/MIPS Patient Centered Medical Home (PCMH) Delivery System Reform Incentive Payment (DSRIP) Transforming Clinical Practice Initiative (TCPI) Advanced Primary Care (APC) Clinical Improvement Activities PCMH 5B, Factors 3 and 4 Project 3.a.i Milestone Milestone 4.4 Six available activities in the Integrated Behavioral and Mental Health subcategory. Can achieve all 60 points needed to get 100% on the category, which comprises 15% of the total MIPS score Practice maintains agreements with behavioral health care providers and integrates with behavioral health care within the practice site. Integration of primary care and behavioral health services through either by co-locating behavioral health services at primary care practice sites or by implementing the collaborative care model Practice ensures that care addresses the whole person, including mental and physical health by providing access to behavioral health services and integrating these services into the primary care setting In Gate 1, practice begins with a selfassessment for behavioral health integration. Gate 2 requires demonstrating use of validated screening tools, as well as adhering to behavioral health quality measures. Gate 3 requires demonstration of patient tracking and follow up 80

81 18 Yankee Stadiums could not hold all of the New Yorkers who have been diagnosed with depression at some point in their lives Approximately 8% of adult New Yorkers experience symptoms of depression each year. 1 12% of NYC mothers exhibit symptoms of depression in the months after giving birth. 2 Major depressive disorder is the single greatest source of disability in NYC. 3 1 New York City Department of Health and Mental Hygiene. New York City Health and Nutrition Examination Survey ( ) 81 2 New York City Department of Health and Mental Hygiene, Bureau of Maternal, Infant & Reproductive Health PRAMS, Muenning, P., Goldsmith, J.A., El-Sayed A.M., Goldmann, E.S., Quan, R., Barracks S., Cheung J., Behavioral Health in New York City: The Burden, Cost, and Return on Investment.

82 COLLABORATIVE CARE OVERVIEW AND IMPLEMENTATION 82

83 83

84 Collaborative Care Principles Patient-Centered Team-Based Care Identify members of care teams and clarify roles Regular case reviews between PCP and Behavioral Health Clinician Establish relationship and communication processes between PCP, BHC and Consulting Psychiatrist Population-Based Care Patient tracked through a registry Process for tracking improvement and following up with patients who are not improving Measurement-Based Treatment to Target Treatment plan clearly outlines goals and are routinely measured by evident-based tools Treatments actively changed if patients not improving as expected Evidence-Based Care Evidence-based practices are utilized to provide more efficient services Accountable Care Providers are reimbursed for clinical outcomes 84

85 SCREENING AND REFERRAL Educate on behavioral health screening best practices and determine who in practice will be doing screenings Determine how patients will be referred to Behavioral Health Clinician (ideal is both warm handoff and electronic referral) Create process for proactive follow up on behavioral health patients 85

86 MUTLI-DISCIPLINARY CARE TEAM Identify members of care team and clarify roles Ensure that PCP and BH Clinician conduct regular case reviews Discuss expectations for administrative staff Determine process for communication with consulting psychiatrist 86

87 CLINICAL OPERATIONS Train PCPs on evidence-based practices for treating common behavioral health conditions Discuss use of pharmacotherapy with support of consulting psychiatrist Develop linkages to community resources and plan to establish formal relationship between practice and community agencies 87

88 Unique Challenges Facing Small Practices Limited staff o Can be mitigated by task shifting/redistributing tasks across health care teams Expense o MHSC allows practices to gain experience working in the collaborative care model, but also aims for future financial sustainability Competing Priorities o Important to find areas of alignment with other programs Time/Resources o Sharing one behavioral health clinician across multiple practice may work well for smaller practices 88

89 Y1 Lessons Learned Understanding of the Collaborative Care Model is essential. Important to sufficiently prepare practices before deploying clinicians to site An engaged site champion is a key to a successful placement!! Using expanded referral criteria can help practices who are having difficulty building substantial caseload for Behavioral Health Clinicians Good communication is a necessity 89

90 For Further Information. Our program is almost full for this year, but we are still accepting applications on a rolling basis For further questions, visit our website OR Contact Laurenn Berger, MHSC Specialist 90

91 Questions? 91

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