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, 2015 11 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 U43MC09134. 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.
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
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 Beyond Beyond Practice: Policy: Implementation: Fostering Diverse Implementing Capturing the Partnerships for Care Coordination Value of Care Successful Care in Practice Coordination Coordination March 30, 2015 May 28, 2015 April 22, 2015
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
Families are Key Members of the Team!!
Care Coordination is Important for ALL these Reasons… and More!
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, MS, FAAP Boston Children's Hospital Harvard Medical School National Center for Care Coordination Technical Assistance richard.antonelli@childrens.harvard.edu
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.
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 hannah.rosenberg@childrens.harvard.edu 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.
Pediatric Care Coordination Community States with entities that are in early stages of engagement. Expressed interest in developing care coordination workforce capacity on level of individual + (RI) + institution and/or state-wide program. + *some sites may have implemented since our last communication + States with entities that have used the + Pediatric Care Coordination Curriculum + as a resource to implement care As of May 1, 2015 coordination workforce capacity building Across these states, as of May 1, 2015, we are + States engaged in statewide aware of over 20 different institutions using the implementation, some partnering Pediatric Care Coordination Curriculum as a with Title V programs resource.
Benefits of Developing a Community Sharing resources Not “re -inventing the wheel ” Learning from others difficulties and successes Potential for collaboration
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!
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
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 Elements of Care Integration Care Health Centers and Private Inter-Professional Education • Boston Children’s Hospital Practices Communications • Portals • “Warm” hand -offs • Primary and Optimal Models of Care • Subspecialty Disease Specific Care • Care Pathways • Collaborative Care Models Tele-health • • Accessibility • Care/ Utilization Management • Care Coordination • Tracking & Registry • Outcomes / Value Centers of Excellence • Quality • Linkage to in-country Population Health Patient/ Family Experience • resources Costs • Integration Collaborator • Integration with specialists
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
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
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
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
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
Care Coordination Framework: Key Elements MA Child Health Quality Coalition CC Task Force www.masschildhealthquality.org/
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
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.
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