One Family s Care Map.

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1 Richard C. Antonelli, MD, MS Medical Director of Integrated Care Boston Children s Hospital, Harvard Medical School Director, National Center for Care Coordination Technical Assistance November 20,

2 Take Home Points Integration is Essential for Success evidence exists Care Coordination is Necessary but not Sufficient to Achieve Integration CC is the set of activities which occurs in the space between Visits, Providers, Hospital stays, Agency contacts Only way to succeed is to engage all stakeholders including patients and families as participants and partners Medical Home is a necessary, but not sufficient, component of high performing system

3 One Family s Care Map

4 Complex Chronic Healthy-- Prevention, Surveillance % of population 0.5% 25% 74.5% % of spend 25% 70% 5%

5 Children with chronic conditions --Behavioral (ADHD, depression, anxiety, PTSD) --Asthma -- Obesity --Diabetes Complex Chronic Healthy-- Prevention, Surveillance Children with complex needs --Neurodevelopmental (Autism, etc.) --Behavioral/Psychiatric --Hematology/ Oncology Sickle cell Hemophilia --Technology dependent

6 Care Coordination Care Coordination is the set of activities in the space between - Visits, Providers, Hospital Stays Turchi RM, Antonelli RC et al. Patient- and Family-Centered Care Coordination: A Framework for Integrating Care For Children and Youth Across Multiple Systems. Pediatrics. May Integrated Care seamless provision of health care services, from the perspective of the patient and family, across entire care continuum. It results from coordinating the efforts of all providers, irrespective of institutional, departmental, or community-based organizational boundaries. Antonelli, Care Integration for Children with Special Health Needs: Improving Outcomes and Managing Costs. National Governors Association Center for Best Practices,

Key Elements 1) Needs assessment, continuing CC engagement 2) Care planning and coordination 3) Facilitating care transitions 4) Connecting with community resources/schools 5) Transitioning to adult

7 Key Elements 1) Needs assessment, continuing CC engagement 2) Care planning and coordination 3) Facilitating care transitions 4) Connecting with community resources/schools 5) Transitioning to adult care Sample Measures Use of a structured care coordination needs assessment tool/process Ask family: did you get what you wanted? Family engagement in co-creation and implementation of care plan Care team members can access, update plan Closing the loop : timely communication after referral visit (to PCP/family/others) Measure bundles, adaptations (HEDIS, CTM-P, CAHPS-PCMH/PICS, ABCD) Link to family partner/family-run org/peers Referral connections made Bi-directional communication of results Acquisition of self-management skills ID adult providers with capacity, expertise 7 t1 t2

8 Family Integrated Model: Accountabilities Across All Stakeholders New Measurement Approaches, Measure Bundles Primary Care Subspecialty Care (Ambulatory ) C.B.O./ EI HMV M-CHAT + Make referral Track referral Registry entry Receive referral Evaluation Care/Treatment Plan Receive report Incorporate into care plan Review with family DPH/Title V Track referrals Track measures (close the loop outcomes) Payer Family-to- Family Support Track referrals Report utilization Quality family and provider experience

9 Overview of measures to track impact of implementing changes Link measures to Triple Aim outcomes! 1.) Improve Patient/Family Experience administer patient/family experience surveys (eg, PICS) 2.) Improve Outcomes Structural and Process Tracking Use of CC needs assessments, care plans, care transitions: between providers; to community resources-- Close the loop performance Track outcomes using CCMT 3.) Reduce Costs Medical expenses: unnecessary ED utilization; rates of hospitalization and unplanned readmissions; duplication of testing/resources 4.) Triple Aim Plus 1-- Provider Experience matters USABILITY & FEASIBILITY Do Not Begin with Pay for Performance!! Provider/care team experience CCMT or other tracking tool time and resources it takes to implement, outcomes achieved from provider perspective

Legend + + + + (RI) states with entities that are in early stages of engagement.

different institutions using the Pediatric Care Coordination Curriculum as a resource + Updated May 1, 2015 +

10 Legend (RI) states with entities that are in early stages of engagement. Expressed interest in developing care coordination workforce capacity on level of individual institution and/or state-wide program.*some sites may have implemented since our last communication Across these states, we are aware of over 20 different institutions using the Pediatric Care Coordination Curriculum as a resource + Updated May 1, states with entities that have used the Pediatric Care Coordination Curriculum as a resource to implement care coordination workforce capacity building + = states engaged in statewide implementation, some partnering with State Title V programs 10

11 State Alaska California Hawai i Massachusetts Michigan Minnesota Oregon Pennsylvania Rhode Island Texas Vermont Wisconsin Partial Overview of Efforts Across the US Area where work is occurring Statewide Regional Regional Delivery System Statewide Statewide Delivery System Statewide Statewide Delivery System Statewide Statewide Pediatric Care Coordination Curriculum Care Coordination Measurement Tool Alignment with triple aim (experience, outcomes, cost) Measures of Care Coordination Measuring Family Experience

12 Key Recommendations Alignment Engage families in your planning from the beginning Leverage PCMH and specialty practice certification AMCHP-- Standards for CYSHCN Health Home funding (Chapter 2703) Meaningful Use Integrate with state agency initiatives and grant-funded programs (USMCHB D 70; CMMI, SIM, DSRIP,others) ACO Development generally, bring CYSHCN care into broader model. Child health specific will take special effort Engage commercial payers in value-based design Employers are also key stakeholders

National Center for Care Coordination Technical Assistance Mission: to support the promotion, implementation and evaluation of care coordination activities and measures in child

The National Center for Care Coordination Technical Assistance is working in partnership with the National Center for Medical Home Implementation (NCMHI) in the American Academy

13 National Center for Care Coordination Technical Assistance Mission: to support the promotion, implementation and evaluation of care coordination activities and measures in child health across the United States. The National Center for Care Coordination Technical Assistance is working in partnership with the National Center for Medical Home Implementation (NCMHI) in the American Academy of Pediatrics. The NCMHI is supported by the Health Resources and Services Administration (HRSA) of the United States Department of Health and Human Services (HHS) grant number U43MC Contact Hannah Rosenberg, Manager, NCCCTA, for more information. Telephone:

Care Coordination Measurement Tool: [http://www.childrenshospital.

17 Care Coordination Measurement Tool: [ US MCHB Pediatric Care Coordination Curriculum [ Care Map [ Care Coordination Strengths and Needs Assessment [ 17

18 References Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. Antonelli R, McAllister J, Popp J.. The Commonwealth Fund. May, MA Child Health Quality Coalition Care Coordination Framework. Funded by the Centers for Medicare and Medicaid Services (CMS) through grant funds issued pursuant to CHIPRA section 401(d). Contact: grogers@mhqp.org AAP Policy Statement: Patient- and Family-Centered Care Coordination: A Framework for Integrating Care For Children and Youth Across Multiple Systems. Pediatrics. May AHRQ Care Coordination Atlas (McDonald Nov 2010, June 2014) and companion document Care Coordination Accountability Measures for Primary Care (McDonald Jan 2012). Care Coordination Measurement Tool (CCMT). Care Coordination for Children and Youth with Special Health Care Needs: A Descriptive, Multisite Study of Activities, Personnel Costs, and Outcomes. Antonelli RC, Stille CJ, Antonelli DM. Pediatrics 2008; Providing a Medical Home : The Cost of Care Coordination Services in a Community-Based, General Pediatric Practice. Antonelli RC, Antonelli DM. Pediatrics Care Transition Measure (CTM Pediatrics). Hospital readmission and parent perceptions of their child s hospital discharge. Berry, Ziniel, Antonelli, Coleman, et al. Internatl Jnl QHC. Aug 2013; Framework of Pediatric Hospital Discharge. Berry et al. JAMA Pediatrics. Aug Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs. Jeanne W. McAllister/Lucile Packard Foundation for Children s Health. May lpfchcshcn.org/publications/research-reports/achieving-a-shared-plan-of-care-with-children-and-youth-withspecial-health-care-needs/ Care Coordination Curriculum and Care Mapping Tool User Guides: Antonelli, Browning, Hackett-Hunter, McAllister, Risko; Lind. Boston Children s Hospital; funded thru Family Voices/MCHB HRSA grant

National Center for Care Coordination Technical Assistance (NCCCTA) Team

National Center for Care Coordination Technical Assistance (NCCCTA) Team Richard C Antonelli, MD, MS, FAAP Primary Care Pediatrician Medical Director of Integrated Care Boston Children s Hospital, Harvard