Care Coordination for Special Populations

Transcription

1 Care Coordination for Special Populations Joy Twesigye, MS, MPP, WHNP-BC Associate Director, Programs and Professional Services June 4, 2013

2 NASBHC Offerings Advocacy Policies Programs Funding Training & Technical Assistance Webinars Free on-line content Professional Services Membership Individual ($75) Organizational ($500)

3 Objectives Identify 3 effective mechanisms of care-coordination. Assess and manage common obstacles for providing care-coordination for special populations. Describe health disparities and social determinants of health that impact special populations.

4 Introductions and Icebreaker Name, Position, Organization Do you have a system to track referrals? Care coordination?

5 Care Coordination as Prevention Mick Wiggins/Getty Images

6 Special Populations and the Safety Net

7 Health Reform and Care Coordination Reimbursement Push for a population-based system Opportunities for care coordination to shine Meaningful use PCMH Quality Measures (CHIPRA/Medicaid)

8 Research Base: Morbidity and Mortality Mortality with heart failure. Mortality and dependency with stroke. Symptoms with depression and at the end of life. Glycemic control with diabetes National Healthcare Disparities Report. January Agency for Healthcare Research and Quality, Rockville, MD.

9 Research Base: Cost Hospitalizations with heart failure. Readmissions with mental health conditions. Cost-effective when applied to treatment of depression.

10 Care Coordination Definitions

11 Care Coordination Definitions The Agency for Healthcare Research and Quality (AHRQ) defines coordinated care as: 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. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. 4

12 Care Coordination Requires a Team

13 Common Care Coordination Approaches System/Sector-based service integration Agency-based service integration Client/Family-based service co-ordination

14 Mechanisms of Care Coordination Service Planning Develop joint action plans Designate organizations/people to perform administrative and service delivery functions Planning to ensure consistency in access to services Understanding the needed but unavailable services

15 Mechanisms of Care Coordination Administrative Functions Setting/Specifying eligibility criteria Monitoring resource allocation Determining discharge or end of qualifying services Determining magnitude of need in order to assign level of service Sharing needs across system, single agency or family

16 Mechanisms of Care Coordination Client Specific Service Delivery Linking client to service providers Making referrals, locating funding Ensuring the accessibility of services Developing an individualized plan Monitoring and evaluating plan implementation

17 Which one is right for you? Care Coordination Case Management

18 Which one is right for you? Care Coordination Case Management Floor Nurse ICU Nurse

19 Care Coordination Across the Life Span Prenatal Care Asthma Diabetes Oral Health Mental Health Asthma Diabetes Oral Health Dialysis Heart Failure Diabetes Multiple Conditions

20 Special Populations: Oral Health NASBHC and Kaiser Permanente Oral Health Initiative 40 grantees

21 Special Populations: Oral Health Assessing clinic capacity Creating referral protocol guidance Brainstorming solutions to obstacles (transportation, dentists not taking Medicaid, staffing)

22 Special Populations: YMSM CDC Funded NASN and Advocates for Youth as National Partners Multi-City New York Philadelphia San Francisco Walton High School, New York City

23 Special Populations: YMSM Building strategic partnerships Documenting linkages of care Creating shareable mechanisms Walton High School, New York City

24 Staffing Solutions Designate a Person in Charge Nurse Social Worker Navigator Community Health Worker (6 week curriculum) Community Health Corps

25 Documentation Policies and procedures Documented responsibilities Letter of agreement

26 Access Solutions: Health Insurance Health Exchanges Enrollment Programs Telephonic Signatures ACA will require in fits_data_trust.pdf

27 Do we have to reinvent the wheel?

28 Care Coordination/Case Management Assessment Tool

29 Referral Protocol Guidance

30 Linkages of Care Guidance

31 Linkages of Care Document

32 Care Coordination and Quality How do they come together?

33 Care Coordination and Quality Core Measures receipt of specialist report Medication management for people with asthma 2014 CMS Adult Core Measures Guidance/Legislation/EHRIncentivePrograms/D ownloads/2014_cqm_adultrecommend_core SetTable.pdf 2013 CMS Child Core Measures Guidance/downloads/SHO pdf

34 Care Coordination and Quality Process Measures Dialysis CT scan Mammogram HPV vaccine Track receipt of services

35 Care Coordination and Quality Outcome Measures Acute Myocardial Infarction* Heart Failure* Pneumonia* Asthma admission rate** Number of school days missed due to illness** 30-day risk standardized readmission measures* National Voluntary Consensus Standards for Patient Outcomes**

36 Care Coordination and Quality Retired Measures Measures that have been removed from tracking due to success over time

37

38 What makes up the Triple Aim? Better care for individuals, Better health for populations, Less cost to the system

39 American adults experience receive recommended care only XX% of the time. 55% 31% 50% 42% 20%

40 American children experience receive recommended care only XX% of the time. 42% 31% 55% 20% 60%

41 Following up with patients is easy

42 Care Coordination is a Billable Service

43 Care Coordination and Case Management is the same thing.

44 What are the Common Care Coordination Approaches? System/Sector-across a set of agencies Agency-integrates services across programs in an agency Client/Family-assists families from agencies

45 Why is focusing on care coordination important? It can be a professional development tool for staff. It improves health outcomes. It is integral to the mission and purpose of clinics. It proves health centers relevance and worth in the safety net. All of the above

46 What is true about care coordination regardless of setting?

47 Questions?