Patient and Family Engagement: Strategies to Improve Health UHF & GNYHA 24 th Annual Symposium on Health Care Services in New York: Research and Practice David Cohen, MD, Maimonides Medical Center
Overview of the Clinical Model Member Key Feature of the BHH model: Virtual co location of providers and services enabled by health h IT and coordination of services 2
Model Engages the Member The Core Team consists of: Care Manager (CM) Care Navigator (CN) Primary care provider (PCP) Admission Alerts Psychiatrist (if needed) Member Therapist (if needed) Other potential team members: Specialty care physicians Peers Home care nurses Residence managers Social workers Substance abuse providers Oh Other caregivers in Health hhome BHIX SHIN NY GSI Health Secure Messaging 3
Care Team Responsibilities Health Information Appointments Referrals Events Develops a single, integrated care plan with members Coordinated Care Plan Reviews individualized treatment plans and goals with members and families Enables members, families and/or other authorized designee to access their care plan Monitoring and Tracking Member Engagement Video Conferences Collaboration Communicate with other providers/peers about a member Evaluate and diagnose a member Develop a treatment plan and reevaluate regularly Update treatment plans Case Conferences Interdisciplinary case conferences Case conference notes captured via Coordinated Care Plan (CCP) with ihautomatic updates Regular communication among care team, specialists, social service organizations, and peers
Care Manager Training Partnering with 1199 Training and Upgrading Fund to develop Care Manager Training Program Topics include: Chronic Conditions and Co morbidities Self Management and Care Management Interventions Risk Assessment Advocacy and Diplomacy Transitions in Care Managing a Caseload Care Coordination Interdisciplinary Teamwork Interdisciplinary Team Care Planning Ethics, Cultural Competency and Health Disparities Patient Centered Communication Motivational Interviewing and Health Coaching 5
Peers Peers are integral part of Care Team Outreach, Engagement, Re engagement, Ongoing Care Management Maimonides partners with Baltic Street and Optum to include Mental Health Peer Counselors in discharge planning process Peer Centered dservices such as Socialization Centers, Recreational and Vocational Programs included in discharge plan Peer Counselors highlight the patient s perspective about the importance of work, leisure activity and community
Platform User Interface/ HH Dashboard Apps Enrollment Care Teams Coordinated Care Plan Alerts Messages EHR SHIN NY EHR Member Engagement Population Manager Member EHR EHR Summary/ CareBook
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Patient Portal: Goals Web based, secure, electronic patient engagement tool Support communication between the patient and the patient s care team Enable the patient to access the patient s personal health information Be available 24 / 7 convenient for patients Meet requirements for Meaningful Use and MedicalHome Recognitionprograms
Patient Portal: Functionality Patients and the Portal Review Care Plan Request appointments Send secure messages Request medication renewal, laborimaging result Educational materials Request a referral Ask for an electronic copy of patient t health lthinformation Enter key information Providers and the Portal Communicate with patients Verify insurance or demographic information Send reminders Send referrals Change appointments Share lab or imaging results Send patient specific health education / information
Pilot Payment and Service Foundation New York State Department of Health Behavioral Health Payments Carved Out Capitated Payment for Medical Services Behavioral Service Provider Behavioral health care Mental health services Substance use rehabilitation services Clinical i l Provider Inpatient and outpatient care Medical and behavioral health services Payer Medicaid MCO Administration Analysis Care Management Provider Care coordination Member engagement Analysis Demonstration: Linking with shared savings Global Risk Pool Based on plan members receiving clinical services at Clinical Provider Risk adjusted Potential lfor savings Other Services Prescription Drugs LTC Services Care Management Fee
Pilot Savings Structure Care Management Provider Behavioral Service Provider Clinical Provider Payer Community Goods Pool Shared Savings Coordination reduces costs Costs of care < risk pool Costs of care > risk pool Global Risk Pool No Shared Savings