Care Navigation Council Nenick Vu Cindy Hochart RN, MBA, PMP Care Navigation Council Director Clinical Advisor to Care Navigation Capitol Health Network Sutherland Health Care Solutions 1
Sacramento’s Healthcare Needs ● Large influx of newly insured Medi-Cal population ● Medi-Cal Managed Health Care System Four health plans - possibly more to come o Four hospital systems o Three IPAs o Seven FQHCs o ● Second most diverse city in America, next to Oakland ● High ER utilization for primary care: Over 50% at Dignity, 15% at Sutter, 25% at UC Davis ● High rates of no-shows to primary and specialty care appointments 2
The Healthcare Policy Landscape Federal Policies ● Affordable Care Act Guarantees Medi-Cal to all low income, legally present residents o Mandates electronic medical records o Incentivizes patient centered health homes o Moves payment systems toward pay for performance measures o Includes Community Health Worker language in the ACA o State Policies ● Movement of Medi-Cal to managed care ● 1115 Waiver - California has applied for federal Medicaid funding to finance Community Health Workers and Peer Support Specialists ● CA adopts ACA Section 2703 Health Homes for complex care patients 3
What does all that mean? State and federal policies are beginning to incentivize expanding healthcare delivery systems to develop a community health workforce that is integrated with local clinical healthcare delivery systems. Sacramento can take advantage of this opportunity to support its diverse, underserved Medi-Cal community to properly access and utilize healthcare services, in order to improve their health outcomes, resulting in savings to health systems. Sacramento can grow its care coordination capacity and sophistication resulting in readiness for Health Homes and new revenue to the providers (90% match for state expenditures) with aim to reduce delivery system costs. 4
The Triple Aim 5
The Care Navigation Model 6
The Care Navigation Council First Phase Goals: 1. Bring together all healthcare stakeholders in the Sacramento region to discuss health care prevention, access, utilization, and management issues, with an emphasis on the functions and roles of community health workers, care coordinators, and navigators in bridging gaps and eliminating barriers within the clinical healthcare delivery system 2. Develop standard language and definitions of roles of community healthcare workers, care coordinators, and navigators 3. Create training and certification programs to support the development of community health workers, care coordinators, and navigators 4. Support the development of pilot projects that integrate community based services to clinical services to ensure that patients properly utilize and access care Second Phase: Advocacy to state policy makers, partnerships with healthcare stakeholders, as well as many other possibilities. 7
Examples of Issues to Address ● Newly enrolled Medi-Cal beneficiaries who are not utilizing any services ● Engaging demographics that are at risk for certain health conditions and not utilizing preventative services Pre-Diabetics, Diabetics, Hypertensive, Hep B, Cancer, SIDS o ● Discharged outpatients who have difficulty finding timely primary care ● High no show rates to specialty care services ● Excessive ER utilization ● Poor health condition management including prescription adherence ● Linguistic issues and barriers ● Lack of culturally competent services 8
Meeting the Triple Aim To meet the Triple Aim, we’ve been able to identify how to improve care for individuals, but we also need to be able to improve the health for whole populations. In order to do so, we need data driven strategies to find patients with similar needs, coordinate across organizations, and deliver services to improve population level health outcomes. 9
Planning for the Future ● The industry is moving to holding practices accountable for outcomes of assigned populations ● Care Navigation and Care Coordination are pivotal to Successful Population Health Management ● Health Plans and Practices are going to need these services to be effective in managing risk of high needs populations ● The focus on reimbursement for these services is on the provider ● Health Homes (2703) adds reimbursement for care coordination of high risk patients in MediCal 10
Where We Are and Where We Need to Be Where we Need to Be Where we are ● ● Many organizations Common understanding of definitions ● ● Clear delineation of scope No common definitions of ● Training/certification available Community Health Workers ● ● Overlapping scope Metrics for service levels, efficiency and ● outcomes by service type No common accountability for ● service levels Self governing collaboration ● ● It becomes easier for Health Plans and No common metrics for efficiency or providers to contract work out than to hire quality ● No systematic collaboration FTEs internally ● ● Define an effective model for the Country Health Plans and practices build ● their own services resulting in Improve economic viability of Care coordination entities system redundancy and higher cost 11
Needs for Effective Care Navigation and Coordination ● Common understanding of terms and scope ● Metrics for effective service delivery ● Clear delineation of scope, processes and outcome expectations ● Resources for training ● Understanding of available community resources to address Social Determinants of health ● Community based record of care coordination that: o provides for a virtual care team o Notifies care team of patient events o Shares common understanding of goals w/ team 12
Need for a Technology Platform ● Patient centered portal for care coordination including community health workers - rather than one portal for each payer/ IPA/etc. ● Accessible by any community based member of a care team with appropriate PHI security ● Simple/easy to use ● Non-duplicative of EMR/EHR ● Timely notifications for patient events (admits/ER) ● Shared information on open gaps in care ● Secure communication between providers who are not aligned in a single organization ● Clear delineation of care coordination roles 13
Building an IT Solution ● Supports all Payers, IPAs and Providers ● Developing feeds from HIE - seeking hospital support for improved transitions of care after hospital discharges and ER events ● Pilot location live in July with first FQHC and first Payer ● Potential for single community based solution for care coordination ● Contains workflows that are easy to use in a busy clinical practice - presents a task list rather than having to search for a patient ● Role based security protects PHI ● Care Navigation/Care Coordination resources in community can use it as part of a designated patient care team at no cost ● Available to hospital systems and payers ● Configurable for goals of sponsor org. - extending closure of gaps into the physician office practice and community care team ● This positions Sacramento for implementation of 2703 health homes since a community based record of care coordination accessible by the whole care team is essential 14
Contact Information Nenick Vu Cindy Hochart nenickvu@gmail.com cindy.hochart@sutherlandglobal.com 916-897-7078 cell/text 816-588-9735 cell/text 15
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