Beyond Implementation: Capturing the Value of Care Coordination

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1 2015 Webinar Series Pediatric Care Coordination: Beyond Policy, Practice, and Implementation A webinar series brought to you by the National Center for Medical Home Implementation Beyond Implementation: Capturing the Value of Care Coordination May 28, am Noon Central This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U43MC This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

2 Beyond Implementation: Capturing the Value of Care Coordination brought to you by the National Center for Medical Home Implementation Moderator: Dian Baker, PhD, RN California State University, Sacramento School of Nursing

Care Coordination in Practice March 30, 2015 Beyond Practice: Fostering Diverse Partnerships for

3 2015 Webinar Series Pediatric Care Coordination: Beyond Policy, Practice, and Implementation A webinar series brought to you by the National Center for Medical Home Implementation Beyond Policy: Implementing Care Coordination in Practice March 30, 2015 Beyond Practice: Fostering Diverse Partnerships for Successful Care Coordination April 22, 2015 Beyond Implementation: Capturing the Value of Care Coordination May 28, 2015

4 AAP Care Coordination Policy Statement. Policy Statement from the American Academy of Pediatrics Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee Lead Authors: Renee M. Turchi, MD, MPH, FAAP & Richard C. Antonelli, MD, MS, FAAP Pediatrics, May 2014

5 Families are Key Members of the Team!!

6 Care Coordination is Important for ALL these Reasons and More!

7 Objectives for Today s Webinar State the value of measuring and evaluating care coordination activities within the context of improved patient experience, improved health of populations, and decreased cost of health care. Identify tools and strategies to facilitate the measurement of pediatric care coordination activities. Provide examples of how practices are utilizing care coordination performance metrics and methodologies to capture value for patients and families.

Beyond Implementation: Capturing the Value of Care Coordination brought to you by the National Center for Medical Home Implementation Richard Antonelli, MD,

8 Beyond Implementation: Capturing the Value of Care Coordination brought to you by the National Center for Medical Home Implementation Richard Antonelli, MD, MS, FAAP Boston Children's Hospital Harvard Medical School National Center for Care Coordination Technical Assistance

9 Disclosures I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

10 National Center for Care Coordination Technical Assistance (NCCCTA) The mission of the center is to support the promotion, implementation and evaluation of care coordination activities and measures in child health across the United States Contact: Hannah Rosenberg 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 U43MC09134.

11 Pediatric Care Coordination Community (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 + + As of May 1, 2015 States with entities that have used the Pediatric Care Coordination Curriculum as a resource to implement care coordination workforce capacity building Across these states, as of May 1, 2015, we are aware of over 20 different institutions using the Pediatric Care Coordination Curriculum as a resource. + States engaged in statewide implementation, some partnering with Title V programs

12 Benefits of Developing a Community Sharing resources Not re-inventing the wheel Learning from others difficulties and successes Potential for collaboration

13 Framework for High Value Care Delivery Model Medical home is an essential component of high performing system, but it needs: Financing Work force development Resources which align with integrated care structures (ie, subspecialties) Technology Collaborative Care Models Integration is essential for success evidence exists!

14 Framework for High Value Care Delivery Model Care Coordination is necessary but not sufficient to achieve integration Care Coordination 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

15 Implications for Accountability Measure at all levels of the system Transparency of performance Incentives supporting activities in the space between Education of work force Support for those activities Support for measurement

Boston Children s Hospital Integrated Care: Elements Which Support a Network of Care Across the Community Community-based Primary Care Health Centers and Private Practices Primary and Subspecialty

16 Boston Children s Hospital Integrated Care: Elements Which Support a Network of Care Across the Community Community-based Primary Care Health Centers and Private Practices Primary and Subspecialty Care Accessibility Care Coordination Tracking & Registry Linkage to in-country resources Integration with specialists Elements of Care Integration Inter-Professional Education Communications Portals Warm hand-offs Optimal Models of Care Disease Specific Care Pathways Collaborative Care Models Tele-health Care/ Utilization Management Outcomes / Value Quality Patient/ Family Experience Costs Boston Children s Hospital Centers of Excellence Population Health Integration Collaborator

17 BCH Integrated Care Program Selected Tools and Processes Care Coordination Capacity Building Pediatric Care Coordination Curriculum Care Coordination Measurement Care Coordination Measurement Tool Family Experience Measurement Pediatric Integrated Care Survey Assessing Hospital Discharge Readiness Care Transitions Measure-Pediatric Care Planning Shared Care Planning Approach, Care Coordination Strengths and Needs Assessment

18 How Care Coordination is Financed: Issues & Opportunities Fee-for-Service (FFS) FFS plus per member per month (PMPM) allowance Global Budget Caveats: Know TRUE costs of care Document care coordination activities and outcomes Affordable Care Act: Opportunities in Accountable Arrangements

19 Integrated Care Pilot Project - Neurology Working with strategic partners Enterprise leadership: physician/nursing/social work Family partners: Federation for Children with Special Needs (Mass Family Voices) Developing relationship with business community Payers National Business Group on Health Discussions re: value proposition of care coordination Outcomes tied to triple aim: better outcomes, better experience, reduced cost

20 Creating High Quality Handoffs What is a Handoff? Transfer of pertinent knowledge between members of a patient s care team, often conducted in anticipation of an upcoming patient encounter. What is the Goal of a High Quality Handoff? To enable the care team to maximize the value of every patient interaction by ensuring relevant knowledge learned by one part of a patient s care team is known to other members at the right time and place. 20

21 Creating High Quality Handoffs (cont d) What are the Elements of a High Quality Handoff? Goal of anticipated encounter, from perspective of the family and PCP Relevant clinical information (eg, clinical findings, labs, imaging results) Model of referral relationship (eg, one-time consult, on-going co-management) Time sensitivity of requests and action items in the care plan 21

22 Care Coordination Framework: Key Elements MA Child Health Quality Coalition CC Task Force

23 Beyond Implementation: Capturing the Value of Care Coordination brought to you by the National Center for Medical Home Implementation Hannah Rosenberg, MSc Boston Children s Hospital National Center for Care Coordination Technical Assistance hannah.rosenberg@childrens.harvard.edu

24 Disclosures I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

25 Care Coordination Measurement Tool (CCMT) Intended to be adapted to reflect activities and outcomes of teams in diverse settings Tool can be implemented in different ways depending on goal of collecting data for every encounter once a week every quarter, etc Paper version or web-based versions have been used in past In AHRQ Atlas, core tool can be found on BCH website:

26 CCMT Background CCMT is a value capture tool designed to track care coordination activities that are currently being done but not being accounted or reimbursed CCMT works to assign value to care coordination activities and get to a true cost of care Initially developed to be a tool used in pediatric primary care practices as a quality improvement initiative CCMT is intended to be adapted by the user/s CCMT is intended to address quality improvement and finance

27 CCMT Today Available in public domain on BCH website Many institutions are using CCMT to capture value of work that they are doing pediatric primary care adult primary care specialty clinics (inpatient and ambulatory) research settings family-partner organizations

29 Adaptation: Questions to Inform Process What is goal of using CCMT to collect data? What will data be used to inform? Who will be completing CCMT? What care coordination tasks do they currently perform? What outcomes occur/are prevented due to these care coordination activities? Does any tool validation need to occur? (further explained later)

30 Implementation: Questions to Inform Process What format will be used to complete CCMT? (Web/paper based?) How often will CCMT be completed? (Think: goal quality improvement/finance)

31 What to Focus on? Quality Improvement If practice/clinic/organization is: Focusing on re-assigning responsibilities/accountability, making sure everyone is working at top of their license In space where already moved from fee-for-service to global budgets Finance If practice/clinic/organization is: In space to inform conversations about financing options Validation (most necessary when addressing finance domain) In past, created vignettes, episode of care Posed to subject matter experts Inter-rater reliability

32 National Study of Care Coordination Measurement in Medical Homes Antonelli, Stille, and Antonelli, 2008 Focus of Encounter: Aggregate Data Primary Focus % Encounters Clinical/Medical Management 67 Referral Management 13 Social Services 7 Education/School 4 Developmental/Behavioral 3 Mental Health 3 Growth/Nutrition 2 Legal/Judicial 1

33 National Study of Care Coordination Measurement in Medical Homes Outcomes Prevented Aggregate Data (32%) of total 3855 CC encounters had something prevented Of the 1232 CC Encounters where prevention was noted as an outcome: Outcome Prevented # Care Coordination Encounters Visit to pediatric office/clinic Emergency department visit Subspecialist visit Percentage

34 National Study of Care Coordination Measurement in Medical Homes 62% of RN CC Encounters prevented something 33% of MD CC Encounters prevented something Non-revenue-generating office nurses drive the most system-level cost savings: avoidance of ED and office visits

Suggestions Involve people who will be collecting data in the adaptation process Ensure that everyone using the tool is working from common definitions, terms

35 Suggestions Involve people who will be collecting data in the adaptation process Ensure that everyone using the tool is working from common definitions, terms (tip: vignettes are helpful in this case) Before actual data is collected, complete trial using a paper version of the tool for staff to get used to using tool

36 Steps to Get This Done Decision to Proceed Why? How long to commit? Expected Outcomes Create Episode of Care model Modify CCMT Implement CCMT Incorporate CCMT in electronic format

37 CCMT Use: Boston Children s Hospital Developed REDCap Tool Link available in EMR Spent time usability/feasibility testing Integrated Care Program Martha Eliot Health Center, Behavioral Health Population

38 Beyond Implementation: Capturing the Value of Care Coordination brought to you by the National Center for Medical Home Implementation David K. Urion, MD Boston Children's Hospital Department of Neurology

39 Disclosures I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

40 40 Baseline Subspecialty Utilization

41 Department of Neurology, Boston Children s Hospital First phase of testing: feasibility/usability of CCMT in clinic

42 Current Quality of Referrals Integration Quality Initial Referrals into Neurology Presence of a referral request: 6.7% Presence of an in-house referral mentioned in a BCH clinical note: 33.3% For patients coming into these pilot sites, little documentation existed regarding source of referral, initial reason for the referral, and expectations of PCP, if any. Integration Quality for Follow-up Visits Follow-up visits generally have no structured mechanism by which the PCP communicates with the subspecialist about new or on-going expectations or needs. Communications are ad hoc or solely dependent on the patient, family, or caregiver to relay to other members of the patient s care team.

43 Closing the Loop Getting Results Where They Need to Be on Time Visits resulting in a lab order 47% Lab order completed 75% Family notified of the test results 77% Referring MD notified of the test results 38% Visits resulting in a consult order 21% Consult order completed 48% Neurologist received consult note 92% Findings based on close the loop measurements conducted for 130 visits across eight clinics in the Department of Neurology from May 2014 to February 2015.

44 Improving Care Transitions Using close the loop measures to confirm improvements in completing lab orders and communicating results in the Rett Clinic: Baseline measurements taken from October 2013 to March Intervention started April 2014 with weekly team conferences to discuss task ownership and order status. Process shifted to an electronic communication process to better fit the team s workflow. * Q data through January and February.

hundred families of children with complex care needs have responded

45 Pediatric Integrated Care Survey (PICS) In the Process of Validation Funded by Lucile Packard Foundation Children s Health More than one hundred families of children with complex care needs have responded to a survey designed to capture the family perspective on care integration.

46 Beyond Implementation: Capturing the Value of Care Coordination brought to you by the National Center for Medical Home Implementation Tami Chase, RN Nurse Manager Martha Eliot Health Center

47 Disclosures I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Martha Eliot puts CCMT into Practice Martha Eliot Health Care urban primary care practice essential part of its community for more than 40 years medical home serving lowincome housing development and

48 Martha Eliot puts CCMT into Practice Martha Eliot Health Care urban primary care practice essential part of its community for more than 40 years medical home serving lowincome housing development and greater Boston community 85% Medicaid, the patient population at Martha Eliot is vulnerable, with poor health status; sizeable CYSHCN population. Significant growth in the Mental Health Department is expected in

49 Utilizing the CCMT at Martha Eliot A new position for the Mental Health Department hired August 2014 The role of the RN provides a layer of clinical management, education, inter-visit and care coordination necessary to meet the complex needs of our population The vision of mental health services at Martha Eliot is to be a leader in the provision of community mental health care CCMT is improvised for Mental Health and used in the EHR CCMT captures data for six months

50 Martha Eliot Demonstrates the Use of CCMT 155 encounters were entered by the RN in a 3 month period between 12/11/14-3/11/15. Data demonstrates clinical expertise of a RN needed in the Mental Health Department Improvements were seen in: compliance to patient visits responsiveness to situation of high patient acuity improved rates in medication compliance preventable patient outcomes

51 Martha Eliot Demonstrates the Use of CCMT Example Data Points used: As a result of this care coordination activity, abrupt medication discontinuation by patient/caregiver was prevented 74.2% of the time (115 times) an encounter was recorded As a result of this care coordination activity, medication treatment continuity and compliance occurred 81.3% of the time (126 times) an encounter was recorded In 97.4% of the encounters recorded, clinical competence was required

52 Questions

53 Resources Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems (AAP Policy Statement) Building Your Medical Home: Care Coordination (Resource Guide) Fostering Partnership and Teamwork in the Pediatric Medical Home: A How-To Video Series National Center for Medical Home Implementation: Care Coordination (Additional care coordination resources)

54 And More Resources Pediatric Care Coordination Curriculum Care Coordination Measurement Tool Care Coordination Measures for Primary Care Practice (AHRQ) MA Child Health Quality Coalition National Center for Care Coordination Technical Assistance at Boston Children s Hospital Hannah Rosenberg, Manager: Hannah.Rosenberg@childrens.harvard.edu

55 We re Here to Help You! Have a question about medical home? Contact the National Center for Medical Home Implementation! Medical_home@aap.org Subscribe to our Listserv! 800/ ext 7605

One Family s Care Map.

One Family s Care Map. 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, 2015