Community-based Care Coordination (CCC) Maturity Assessment RidgePointe Healthcare District
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- Aubrey Poole
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1 Who/What Program Elements Level 1. Beginning Level 2. Progressing Level 3. Intermediate Level 4. Advanced Organization(s) sponsoring CCC Providers Community services Patients (pts) Payers A. LEADERSHIP - Transformative change - Community engagement - Goal setting - Team-based, patientcentered care - Evidence-based care - Innovative delivery models Sponsoring organization(s) on board Providers notified Community services relationship building initiated Business case for accountable care anticipated on board CCC on board Providers on board Triple Aim goals identified Some community services on board Payers engaged in goalssetting Communications with pt representatives about CCC Many community services on board CCC extends to ToC & fees received Community steering committee in place Learning about or implementing new models of care Triple Aim goals measured & refined All members of community embrace new models of care Care coordination fully actuated Triple Aim goals being met Patients Primary Care Provider (PCP) panels Specialties CCC cohorts Population B. PATIENT POPULATION / PANEL MGMT - Patients assigned to PCP - Results tracking - Appointment F/U calls - Referrals tracking - Risk stratification to balance panel size - Panel maintenance Patients assigned to PCPs Results tracking for all patients CCC cohorts identified for care management Appointment F/U calls for high-risk pts Referrals tracking for high risk pts CCC cohorts managed through ToC Risk stratification to balance panel size Panel composition maintained Consumer experience of care measured Consumer experience of care improved Providers share savings Emergency department Observation Hospitalization Clinical pharmacy Rehabilitation Nursing home C. CARE MANAGEMENT - Pre-admission o Clinical summary o Triage - Admission o Care plan o Medication reconciliation o Case review o Shared decisions - Discharge planning o Care plan o Instructions o Clinical summary Treatment plan exists for all pts Local medication reconciliation by nursing staff Discharge instructions given to pt/caregiver Clinical summary provided to pt manages transfers to nursing home/rehab Clinical summary shared with next provider &/or PCP Clinical summaries obtained for all high-risk pts admitted CCC conducts case review for high-risk pts during care Clinical pharmacist engaged in local medication reconciliation CCC reviews discharge care plans with high-risk pts CCC engaged in preadmission triage CCC engaged in care planning during admission Pts & providers engaged in shared decision making CCC actively engaged in discharge care planning for high-risk pts Level of care utilization improved 30-day readmissions & ED frequency reduced Medication safety outcomes improved Section Assess CCC Maturity Assessment Example and Report - 1
2 Who/What Program Elements Level 1. Beginning Level 2. Progressing Level 3. Intermediate Level 4. Advanced Community setting o Home o Assisted living o Domiciliary o Rest home Home health Hospice Retail pharmacy D. TRANSITIONS OF CARE (ToC) - CCC calls, visits highrisk patients - Medication monitoring - Care plan monitoring - Health literacy & education o Medications o Life style changes o Screenings o Immunizations - Pt engagement; pt self-management - Health outcomes monitoring reviews clinical summary & instructions prior to discharge provides education as appropriate conducts courtesy calls for high-risk pts, reviews medication compliance CCC engages patient in post-discharge care planning; assesses health literacy CCCs calls high-risk pts to monitor medication, care plan compliance CCC discusses life style changes CCC encourages home monitoring; educates pt on potential solutions Retail pharmacist engaged in medication safety reviews CCC F/U on screening & immunizations CCC calls & visits high-risk patients F/U calls for care plan monitoring; encourages self-management through motivational interviewing & use of community services Retail pharmacist engaged in medication management (fill status notification) CCCs address special populations: o Pre-natal o Special needs children o Depression/BH Population health outcomes Pts engaged in selfmanagement Nutrition Transportation Support groups Homemaker Respite Social services Local public health Housing Vocational Schools E. COMMUNITY RESOURCES - Identification - Utilization - Directory - Formal agreements - Online availability checking - Online arrangement for services Initiation of community resources identification Information exchanged with community resources about CCC & accountable care Agreements with services most used by high-risk pts CCC makes referrals to community resources, facilitated by directory of services, availability Many agreements across range of community resources CCC arranges for community resources directly online Active use of community resources Improved consumer experience of care Community resources included in shared savings Section Assess CCC Maturity Assessment Example and Report - 2
3 Who/What Program Elements Level 1. Beginning Level 2. Progressing Level 3. Intermediate Level 4. Advanced Electronic health record (EHR) Data mgmt. Workflow & Process mgmt. Health information exchange (HIE) Data warehouse o Registry functionality o Risk strat. o Data analytics o Financial modeling o Evidence-based practices Telehealth Home monitoring device integration Personal health record (PHR) Community core measures of quality & cost o Reporting o Improvement Payer participation in performancebased payment (PBP) F. DATA & PROCESSES - Access to data - Use of data in clinical decision making - Exchange of data - Clinical quality measurement (CQM) reporting & - Data used for knowledge management G. QUALITY MANAGEMENT H. FINANCIAL MANAGEMENT EHR MU initiated; CQMs reported via data abstraction Structured data required for MU in place Workflow & process management is recognized as a key factor for successful use of technology Limited (push via Direct ) HIE Registry functionality used for some clinical care tracking Pts encouraged to use home monitoring devices <70% quality measures met in each domain Core measures quality reporting limited to local providers, in aggregate quality reporting to local providers in aggregate <5% performance-based payment (PBP) MU functionality used by minimum required number of providers; esubmission of CQMs Clinical summaries in structured data format (C- CDA) Adoption of standard vocabularies Limited clinical & financial data integration Workflow & process mapping initiated Participation in HIE (for pull/query support) by providers Registry used for preventive care Pts encouraged to maintain health diary & share through portal, Direct , PHR Reimbursable telehealth services adopted 70% - 79% quality measures met in each domain Core measures quality reporting at provider & pt level of specificity Core measures quality data publicized in aggregate cost reporting initiated EHR is meaningfully used by all providers Increased clinical & financial data integration to measure cost of care on core measures All providers & community services online 24x7 Workflows & processes continuously monitored for Community services initiate participation in HIE Registry functionality used for all pt F/U Home monitoring device data integrated with EHR Telehealth integrated into accountable care model 80% - 89% quality measures met in each domain Care coordination cost effectiveness Pharmacy cost effectiveness quality data publicized at provider level 5% 15% PBP 15% 30% PBP >30% PBP Integrated risk stratification Big data analytics provide feedback loop for evidencebased clinical decision support Triple Aim outcomes compared to baseline &/or benchmarks for continuous 90%+ quality measures met in each domain Per capita cost reduced quality & cost data publicized at provider level Section Assess CCC Maturity Assessment Example and Report - 3
4 Summary Report Element Level 1. Beginning Level 2. Progressing Level 3. Intermediate Level 4. Advanced A. Leadership B. PT Population / Panel Management C. Care Management D. Transitions of Care E. Community Resources F. Data and Processes G. Quality Management H. Financial Management NOT ASSESSED NOT ASSESSED Program Element A: LEADERSHIP Maturity Level: PROGRESSING General assessment: (RidgePointe) is making good progress in the Leadership element of a Community-based Care Coordination program. The sponsoring organization (RidgePointe Hospital), most providers (other than specialty providers), a community-based care coordinator and a number of community resources are on board with the program. One payer organization (Blue Cross Blue Shield) has been engaged in setting goals for the program, patient follow-up and standards of care. Communications about CCC has taken place with at least one patient representative. [Level 1: 5/5; Level 2: 5/6] Program Element B: PATIENT POPULATION / PANEL MANAGEMENT General assessment: RidgePointe is in the beginning stages of Patient Population / Panel Management. In general, patients provider preferences are noted but they are not assigned to primary care providers (PCPs). Patients haven t yet been identified for care coordination. A process for tracking test or lab results is in place. In addition, referral tracking through follow-up calls is currently done for all patients. [Level 1: 1/3; Level 2: 2/3] Program Element C: CARE MANAGEMENT General assessment: RidgePointe is in the beginning stages of Care Management. Some care management activities are currently being done, such as treatment plans for all patients, medication reconciliation, and verbal clinical summary sharing with other providers. Discharge instructions are provided verbally to patients. Transfers to nursing home or rehab are done by the LSW working with the patient and family. Clinical summaries are obtained for high-risk patients admitted. [Level 1: 4/6; Level 2: 1/4] Section Assess CCC Maturity Assessment Example and Report - 4
5 Program Element D: TRANSITIONS OF CARE (ToC) General assessment: RidgePointe is in the very beginning stages of Transitions of Care (ToC). Clinical summaries and instructions are reviewed with patients prior to discharge by the RN on duty, not by the care coordinator. Patient education is given by NP and provider. [Level 1: 1/3] Program Element E: COMMUNITY RESOURCES General assessment: RidgePointe is in the beginning stages using Community Resources to support its Communitybased Care Coordination program and will continue to build on relationships already established. Information about CCC and accountable care has been communicated with some community resources, and a number of representatives from community services attended the CCC Program launch meeting. [Level 1: 2/2] Program Element F: DATA AND PROCESSES General assessment: RidgePointe is in the beginning stages using Data and Processes to support its Community-based Care Coordination program. Staff recognizes that workflow and process management as a key factor for successful use of technology, and works with patients to use home monitoring tools and devices such as glucose meters, blood pressure monitors, and diet history/diaries. [Level 1: 2/6] Program Element G: QUALITY MANAGEMENT NOT ASSESSED Maturity Level: N/A General assessment: N/A Program Element H: FINANCIAL MANAGEMENT NOT ASSESSED Maturity Level: N/A General assessment: N/A Section Assess CCC Maturity Assessment Example and Report - 5
6 Copyright 2014 Stratis Health and KHA REACH. Updated 12/12/2014 Section Assess CCC Maturity Assessment Example and Report - 6
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