Goals of Module One CC4C Orientation Module One Identify all agencies involved in the CC4C Partnership Present a brief description of each partner Introduce an overview of CC4C services Share resources for CC4C Care Managers 1 2 Care Coordination for Children (CC4C) Brings together: State Partners: DMA, DPH, & CCNC Central Office Local Partners: LHDs & CCNC networks CC4C & CCNC care managers to 1) improve quality of care for children & families, 2) increase efficiency through collaboration, and 3) decrease cost. 3 Community Care of North Carolina 4 Community Care of North Carolina North Carolina Medicaid 1.5 Million Medicaid Recipients 1,233,000 enrolled in a CCNC Medical Home Statewide Program for Managing Carolina Access Recipients 5 1542 Practices 4500+ Providers 6 1
CCNC Origins Medical Home Capacity & Accountability Started with 9 pilot networks Single-disease initiatives 1998 asthma (data-driven, evidence-based guidelines, population-management approach, rapid cycle QI) Other initiatives followed (DM, HF, etc.) Achieved cost-savings & improved quality of care 9 pilot networks grew to 14 Sustained Networks in 100 counties Local Community Care Networks 7 8 Community Care Networks CCNC Networks Non-profit, Physician-led, Locally owned and operated organizations Receive a designated amount of $$$ per Medicaid recipient enrolled in a CCNC practice in their Network per month from the Medicaid (Division of Medical Assistance/DMA) Funds the Primary Care Management model Partner with other safety net providers Use existing resources to build better local systems of care local flexibility to create local solutions to local issues Have Medical Management Committee oversight & Board of Directors Participating Practices receive an enhanced pm/pm incentive to function as a medical home and participate in CCNC Initiatives (disease management and quality improvement) Legend AccessCare Network Sites AccessCare Network Counties Community Care of Western North Carolina Community Care of the Lower Cape Fear Carolina Collaborative Community Care Community Care of Wake and Johnston Counties Community Care Partners of Greater Mecklenburg Carolina Community Health Partnership Community Care Plan of Eastern Carolina Community Health Partners Northern Piedmont Community Care Northwest Community Care Partnership for Health Management Community Care of the Sandhills Community Care of Southern Piedmont 9 10 CCNC Network TEAMS FOCUS of CCNC >1500 Medical Homes/4500 Providers 14 Network Directors 30 Local Medical Directors >500 Local care managers (Embedded = 118 practices 48 hospitals) 14 Local Psychiatrists >20 Local Clinical Pharmacists 14 Local Palliative Care Champions 14 Local Quality Improvement Teams Partner w/local hospitals, health dept., other community agencies CENTRAL SUPPORT: Team of clinical, quality, and data experts; Call Center Informatics Center providing Quality & Care Management data to networks, practices, hospitals, other partners 11 improved quality, utilization and cost effectiveness of chronic illness care 12 2
Managing Clinical Care (Spreading Best Practice) Chronic Care Model Over time, visits/interactions (planned and acute) will meet patient needs and assure the delivery of proven clinical and behavioral elements of care. INFORMED ACTIVATED PATIENT PREPARED PROACTIVE TEAM IMPROVED OUTCOMES 13 http://www.improvingchroniccare.org 14 CCNC Network Teams Support the Medical Home Main Program Activities Local Network Team Provider Engagement Patient Engagement Evidence-Based Guidelines Education, Referrals, Follow-Up Process Improvement Outcome Improvement Improved Care Improved Utilization 15 Management of Priority Populations *TREO Priority Population List (PPL) *Patients in the Hospital/Transitional Care *Real-Time Referrals *Other Data Reports Chronic Disease Management of Key Conditions (e.g. Asthma, Diabetes, Heart Failure, Hypertension, Ischemic Vascular Disease, Mental Health Conditions) Medial Home Quality Improvement Activities Emergency Department Utilization Integration of Physical and Mental Health Chronic Pain Initiative Prevention Initiatives Pharmacy Initiatives Palliative Care Informatics Center/Pharmacy Home/Provider Portal/CMIS 16 A few of the challenges The General Assembly charged DHHS (and CCNC) to save $90 million in FY2012 (July 2011 thru June 2012). As of 8/11, enrolled ABD population ~ 205,400 (total ABDs >361,000; NC Medicaid population ~1.48 MM; those enrolled in Carolina Access II & III > 1,082,000). With health reform, the NC Medicaid rolls may grow by more than 500,000 new recipients by 2014. Primary Goals of Community Care Improve the care of Medicaid population while controlling costs A medical home for patients, emphasizing primary care Community networks capable of managing recipient care Local systems that improve management of chronic illness in both rural and urban settings Total ABD population represents less than 25% of NC s Medicaid population, but consumes more than 70% of Medicaid dollars.0% of Medicaid dollars. 17 18 3
CCNC Nationally Recognized Impact www.communitycarenc.org/ 19 20 Division of Public Health 21 22 Definition of Public Health: Public health consists of the activities that society undertakes to assure the conditions in which people can be healthy, including organized efforts to prevent, identify and counter threats to the health of the public. Mission of NC Public Health: To promote and contribute to this highest level of health possible for the people of NC. From Introduction to Public Health http://www.sph.unc.edu/nciph/introduction_to_public_health_in_nc_6386_7857.html 23 Ten Great Public Health Achievements in the United States, 1900 1999 1. Vaccination 2. Motor vehicle safety 3. Safer workplaces 4. Control of infectious diseases 5. Decline in deaths from coronary heart disease and stroke 6. Safer and healthier foods 7. Healthier mothers and babies 8. Family planning 9. Fluoridation of drinking water 10. Recognition of tobacco use as a health hazard 24 4
Title V of the Social Security Act Is a block grant program Is administered by the Maternal and Child Health Bureau (MCHB) within the US Dept of Health & Human Services Combines Federal, State, and local funds to provide comprehensive services to low income women and children with limited access to health care services 25 Title V of the Social Security Act Medicaid, the Children s Health Insurance Program (CHIP or NC Health Choice) and Title V serve many low income women and children, including children with special health care needs. Medicaid and CHIP provide free or low cost health insurance to eligible participants. Title V provides Federal block grant funds to States, where they support comprehensive services to women and children with limited access to health care services. The Title V Agency in NC is the Women's and Children's Health Section within NC Division of Public Health 26 Title V MCH Programs 1. Assure access to quality care, especially for those with lowincomes or limited availability of care; 2. Reduce infant mortality; 3. Provide and ensure access to comprehensive prenatal and postnatal care to women (especially low income and at risk pregnant women); 4. Increase the number of children receiving health assessments and follow up diagnostic and treatment services; 5. Provide and ensure access to preventive and child care services as well as rehabilitative services for certain children; 6. Implement family centered, community based, systems of coordinated care for children with special healthcare needs; and History of DPH Care/Case Management for Children ages 0 5 years Began the High Priority Infant Tracking program in 1978 Expanded and name changed to Child Service Coordination Program (CSCP) in 1989 Initially viewed CSCP as a care coordination service With HIPAA code conversion in 2002, CSCP became a targeted case management service 7. Provide toll free hotlines and assistance in applying for services to pregnant women with infants and children who are eligible for Title XIX (Medicaid). CSCP services ceased on February 28, 2011 27 28 Example of National Public Health Initiatives http://medicalhomeinfo.org/ Example of NC Public Health Initiatives 29 29 http://www.ncpublichealthquality.org/ctr/ 30 5
From Introduction to Public Health http://www.sph.unc.edu/nciph/introduction_to_public_health_in_nc_6386_7857.html 31 32 32 http://publichealth.nc.gov/ Additional PH Resources This is Public Health campaign by Association of Schools of Public Health View This is Public Health Video at: www.thisispublichealth.org/video_highres.html Learn more about This is Public Health Campaign at: www.thisispublichealth.org/ Introduction to Public Health a free online, one hour course at: http://www.sph.unc.edu/nciph/introduction_to_public_ health_in_nc_6386_7857.html 33 34 Local Health Departments 35 As of 1949, each NC county had established a local health department (LHD) Today, all 100 counties are served by an individual LHD, except for the following multi county health departments: Albemarle District (Bertie Camden Chowan Currituck Gates Pasquotank Perquimans) Appalachian District (Alleghany Ashe Watauga) Granville Vance District Martin Tyrrell Washington District Rutherford Polk McDowell District Toe River (Avery Mitchell Yancey) District Each LHD is governed by a local Board of Health 36 6
http://www.ncalhd.org/county.htm 37 http://www.ancbh.org/ 38 Care Coordination for Children Beginning March 1, 2011 Local Health Departments began providing Care Coordination for Children (CC4C) services in partnership with local CCNC networks. The name of the CC4C service provided by LHDs is population Care Management. The LHD staff providing CC4C services are referred to as CC4C Care Managers. 39 40 CC4C Target Population Children from birth to 5 years of age (both Medicaid & non Medicaid) who are: Children with Special Health Care Needs NICU Babies In Foster Care & Not Linked to a Medical Home Exposed to Toxic Stress in Early Childhood Children Flagged on a Priority Population List Based on Above Expected Potentially Preventable Hospital Costs CC4C Responsibilities CC4C CMs are responsible for all the children 0 5 in their county who are in the CC4C Target Population. In order to meet this responsibility, CC4C CMs will: level the service based on the family s needs (e.g. heavy, medium, light) determine the length of time that services are provided depending on family s need and evidence that progress is being made Other children identified through claims data reports that could benefit from follow up and/or transitional care services 41 42 7
CC4C Medical Home Responsibilities CC4C CMs are required to work with the Medical Homes (MH) by: Linking or embedding CC4C CMs with MH practices Communicating and collaborating with MH for children in CC4C Target Population in order to best meet child/family needs Note: Recruitment of CC4C MH is not a program focus, as most MHs serving children 0 5 years were already enrolled as CCNC providers. However, assuring that children we serve are linked to Medical Homes is a priority. 43 44 Performance Metrics CC4C Contract Metrics [Reported to DMA] PM #1: Increase in NICU graduates who have their first PCP visit within one month of discharge. PM #2: Reduce the rate of hospital admissions for children birth to <5. PM #3: Decrease the rate of readmissions for children birth to <5. PM #4: Performance Metrics CC4C Contract Metrics [Continued] PM #5: Increase percent of comprehensive assessments completed for CC4C patients identified as having a priority (heavy/medium case status). PM #6: Increase the Life Skills Progression (LSP) Assessments for the targeted population of children ages birth to five (Toxic Stress) receiving care coordination through CC4C on entry into the system, every six (6) months thereafter and/or upon closing. Reduce the rate of ED visits for children birth to <5. 45 46 CC4C Program Measures Increase the # (and rate) of infants < 1 year of age referred to Early Intervention (EI) Program. Increase the percent of children with special health care needs enrolled in a medical home. Increase the percent of children in foster care who are enrolled in a medical home. 47 MEASURES Success = Meeting Performance Metrics and Program Measures Meeting Measures depends on: 1. # of children touched 2. Actions taken when touching CCNC has long history of meeting measures that demonstrate quality & cost. 48 8
CC4C Funding To assist in meeting the responsibilities of the CC4C Target Population, the LHDs: receive a Per Member Per Month (PMPM) allocation to serve Medicaid clients; amount of PMPM is based on the number of Medicaid children 0 5 years in each county. have the opportunity to draw down CC4C Agreement Addenda funding to serve non Medicaid children; level of funding is consistent with past CSCP AA funding. 49 Cheryl Lowe CC4C Program Manager Division of Public Health WCH Section / C & Y Branch Work Cell: 336 813 2068 cheryl.lowe@dhhs.nc.gov CC4C Program Development CC4C Workgroup DPH, DMA, CCNC s Central Office, Physician Community, Local CCNC Networks, Local HDs & the DPH C&Y Family Council. Carolyn Sexton CC4C Project Manager CCNC Central Office Office: 919 745 2428 carolyn.sexton@dhhs.nc.gov 50 Care Coordination for Children Exhibit A: LHD responsibilities in providing CC4C services (page 11) Exhibit B: CC4C Performance Measures (page 15) Exhibit C: Payment (page 16) Pulling it all together 51 52 Care Coordination for Children (CC4C) A critical component to the success of the CC4C Program is establishing a close relationship between the local CCNC & the LHD To achieve a fully integrated and collaborative system of care, decisions about how to manage the targeted populations must be decided at the community level building on the strengths and resources that each partner offers. Together we will also need to determine how we can build strong, stable relationships and communications between CCNC Care Managers, CC4C Care Managers and the Medical Homes they serve. Together we will monitor progress and discuss strategies for achieving the outcome measures of the CC4C Program (many of which are objectives that we share). 53 CC4C Resources 54 9
Possible Responsibilities of Network Lead CC4C Contact 1. Responsible for CC4C and other network duties 2. Facilitates regular meetings of local CC4C staff 3. Provides CMIS support 4. Monitors CMIS activities 5. Knowledgeable of Medical Homes in each county 6. Works with local Medical Homes to ensure close working relationship with CC4C CMs 7. Discusses local network case load & face to face expectations 55 56 Possible Responsibilities of DPH Regional Child Health Nurse Consultants (CHNCs) 1. Provides technical assistance to a region of LHDs for CH Programs, including CC4C 2. Monitors the number of cases and staffing 3. If a need is identified, works with the agency using QI tools to develop a step by step plan to address the need, including timelines. 4. Provides support to regional meetings for CC4C staff and network staff (role varies from network to network). 5. Support CC4C CM orientation and training needs. 6. Provide training and support to local health department staff on using the Quality Improvement Model. REGION 1A Linda Harrison linda.harrison@dhhs.nc.gov Phone: 828-369-6940 Fax: 828-369-8231 Cell: 828-342-4265 REGION 2 Melody McCune melody.mccune@dhhs.nc.gov Phone: 336-940-2358 Fax: 336-940-2349 Cell: 704-662-2108 REGION 4 Stephanie Fisher stephanie.fisher@dhhs.nc.gov Office: 919-266-9524 Fax: 919-266-9527 Cell: 252-571-2387 REGION 5 Lynette Robinson lynette.robinson@dhhs.nc.gov Office: 252-223-2016 Fax: 252-223-2029 Cell: 252-514-5905 REGION 1B 2 3 4 5 Alleghany Northampton Surry Rockingham Gates Currituck Robin Byrne Ashe Caswell Person Vance Stokes Warren robin.byrne@dhhs.nc.gov Watauga Granville Halifax Hertford Wilkes Phone: 828-697-4615 Yadkin Forsyth Alamance Bertie Mitchell Avery Franklin Bertie Fax: 828-697-4616 Caldwell Davie Guilford Orange Durham Nash Alexander Davie Edgecombe Cell: 919-624-6652 Madison Yancey Tyrrell Burke Iredell Davidson Wake Martin Washington Dare Randolph Chatham Wilson Buncombe McDowell Catawba Rowan Greene Pitt Beaufort Swain Haywood Johnston Greene Hyde Rutherford Lincoln Cabarrus Montgomery Lee Graham Henderson Harnett Wayne Jackson Polk Cleveland Gaston Stanly Moore Lenoir Craven Cherokee Macon Transylvania Mecklenburg Sampson Clay Pamlico 1B Richmond Hoke Cumberland Jones Union Duplin Anson Scotland 1A Onslow Carteret 6 Bladen Robeson Pender Map available at: http://ncdhhs.gov/dph/wch/doc/aboutus/maps/chnc-map-020112.pdf Columbus New Hanover REGION 3 Brunswick STATE CHILD HEALTH NURSE CONSULTANT Jean Vukoson jean.vukoson@dhhs.nc.gov Office: 919-707-5644 Cell: 919-609-2904 Fax: 919-870-4880 CHILD CARE FOR CHILDREN (CC4C) PROGRAM MANAGER Cheryl Lowe cheryl.lowe@dhhs.nc.gov Cell: 336-813-2068 Effective February 1, 2012 BEST PRACTICE NURSE CONSULTANT Jackie Harrell jackie.harrell@dhhs.nc.gov Cell: 252-678-3247 REGION 6 Angel Callicutt angel.callicutt@dhhs.nc.gov Office: Fax: Cell: 919-218-6522 Chowan Camden Pasquotank Perquimans STATE CHILD CARE CONSULTANT Debra Garrett debra.garrett@dhhs.nc.gov Office: 919-707-5646 Fax: 919-870-4880 57 Department of Health and Human Services Division of Public Health Women s and Children s Health Section Children & Youth Branch Child Health & CC4C Nurse Consultants Regional consultants are initial contact for CC4C & Child Health programs 58 CC4C Webinar for Supervisors & Care Managers Care Coordination for Children 1 st Thursday of every month 2:00 p.m. Via the internet Announcement sent via the CC4C Email List Handouts posted on the CC4C Training Web Page at http://childrenyouth.cc4c.sgizmo.com/s3/ 59 Strong Partnership = Success 60 10