Helping to create healthy communities by supporting vibrant and Care Coordination effective community health centers Tara Ferguson Clinical Quality Coordinator Alaska Primary Care Association 1231 Gambell Street, Suite 200 Anchorage, Alaska 99501 Main: 907-929-2722 Direct: 907-929-8104 taraf@AlaskaPCA.org
Care Coordination • Fundamental • Challenging • Innovative • Requirement − Health Resources and Services Act (HRSA) − Patient Centered Medical Home (PCMH) • Accreditation Association for Ambulatory Health Care (AAAHC) • The Joint Commission (TJC) • National Committee for Quality Assurance (NCQA) • Reimbursement disparity 2
Provided by • Support staff • Certified Nurse Assistant/Certified Medical Assistant • Registered Nurse • Community Health Aides / Behavioral Health Aides • Midlevel Providers (Nurse Practitioners & Physician Assistants) • Physicians • Care Teams (comprised of a combination of above) 3
Services Provided • Test tracking and follow-up (labs & imaging) • Tracking and follow-up of • Hospital admissions • Emergency room visits • Scheduling appointments with specialists • Supporting treatment plans • Referrals • Completing with provider and/or care team • Internal / external • Submitting, tracking and follow-up until closed • Prescription refill coordination • Care Transitions • Communication with Community Partners (child or adult protective services, foster care, detention centers) 4
Services Provided Care assistance during visits with provider Attending Care Team huddles Facilitating care as needed Attending appointments Travel Coordination Eligibility Screening or the facilitation of (Sliding Fee, Medicaid and/or Children’s Health Insurance Program, Medicare, public health insurance) Identifying & linking to potential resources (Nutrition, Parenting, Falls Prevention, Meal support, etc…) 5
Comprehensive • Touches the patient when care is first identified to include: • Lifespan (Birth to death) and includes: • Population health management identified (age specific preventive care, chronic disease) • Healthcare need arises (Acute or Emergent) • Throughout the continuum of care • Resource Dependent 6
Population Health Focus • Assess population • Registries • PCMH • Integrated Care Team • Huddles • Health Indicators and quality outcomes • Proactive vs Reactive Approach to care • Transparency 7
Reimbursement • Current status – mostly uncompensated • Current opportunities for reimbursement *PCMH efficiencies support operations • Future *SB74 opportunities – demonstration projects • Section 2703 Health Home Waiver • Future reimbursement on PMPM or other methodology 8
How Comprehensive could it be? • Alaska Medicaid system-wide Care Coordination Model • Local level That ties in to State level • Statewide HIE • Appropriate reimbursement methodology 9
APCA has experience with Care Coordination • Hands on experience • Tribal • Non-Tribal • Staff trained in PCMH Standards that include Care Coordination • Staff experienced in Practice Facilitation assisting Primary Care Practices with Care Coordination • Call us with your questions around Care Coordination 10
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