AccessCare

1. AccessCare Courtney Cantrell, PhD Lead Behavioral Health Coordinator

2. CCNC Origins • 1998, 9 pilot networks, ~120,000 enrollees • Single-disease initiatives, starting with asthma in 1998 (data-driven + impactable population + clearly-defined “best practices” + volume + clear guidelines = success) • Other initiatives followed every 2-3 years (DM, CHF, et al.)

3. CCNC Infrastructure • 14 Networks - private, non-profit organizations • Community-based, physician-led, emphasis on medical homes • Local partners = hospital, health department, DSS, specialists, etc • Partner with the state to better manage Medicaid population = improve quality and contain cost • Enhanced pmpm to Medical Home • Improved quality, utilization and cost effectiveness of care

4. CCNC 2011 - updating

5. CCNC/CA: THE BENEFITS OF BEING A MEMBER-MEDICAID

6. Target Population • Within the Medicaid population, there are approximately 200,000 Aged, Blind, or Disabled (ABD) recipients enrolled in CCNC networks • ABD recipients make up approximately30%of our Medicaid population but consume around 70%of total Medicaid expenditures

7. Major Co-morbid Conditions Within the 200,000 ABD Medicaid Recipients • 24% Diabetes • 45% Hypertension • 13% Ischemic Vascular Disease • 12% Neurological Disorders • 6% Chronic Kidney Disease • 41% Mental Health conditions

8. FOCUS of CCNC improved quality, utilization and cost effectiveness of chronic illness care

9. CCNC Care Management

10. Care Management Services • Strengthen link to Primary Care Provider • Ensure patient has accessible medical home • Bridge communication between patient and Provider • Close follow up with primary physician with evidence of instability • Address ED utilization, importance of regular chronic care visits • Identify and lessen barriers to self-care • Enhance basic disease knowledge and self help skills of patients • Support behavior change related to lifestyle (diet, exercise, etc.) • Try to maximize compliance of prescribed medicines • Address language, transportation, literacy, other barriers • Education around daily management, target ranges, warning signs, diet, tobacco, medications, physical activity, screenings and prevention of complications, etc. Identify and strengthen link to community resources • Specialist care ( cardiologist, mental health, ophthalmologists, etc. ) • education programs, support groups, exercise programs

11. Transitional Care Process • Hospital visit & collaboration • Face to face visit following discharge • Medication reconciliation • Facilitate PCP/Specialist follow-up visit • Link, support, educate, monitor, etc.

13. CCNC / AccessCareWhat Does the Research Say? • Analyses confirm the overwhelming pervasiveness of physical and behavioral health co-morbidity among Medicaid’s highest-cost beneficiaries. • CCNC findings demonstrate that most beneficiaries with the highest hospitalization rates and costs have not one condition, but many. • Mental illness is nearly universal among the highest-cost, most frequently hospitalized beneficiaries, and similarly, the presence of mental illness and/or drug and alcohol disorders is associated with substantially higher per capita costs and hospitalization rates. CHCS Center for Health Care Strategies, Inc., Dec 2010 ‘Clarifying Multi-morbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations’

14. right CARE TEAM • CCNC Team - PCP/Medical Home, Primary Care Manager (RN/SW), Behavioral Health Coordinator, Network Pharmacist, Network Psychiatrist, other as appropriate • Behavioral Health Team – LME, Mental Health Providers, Targeted Case Management

15. Working Together • Attend AccessCare-Smoky LME meetings discussing care of high utilizing patients as needed • Identify Medicaid recipients that may benefit from care management (refer to DSS for enrollment) • Participate in medication reconciliation process when requested • Attend meetings with PCPs (Primary Care Physicians) • Share data • Provider Portal Data requests through AccessCare or Smoky LME—no wrong door • Work with assigned care manager on shared patients; e.g., share Person Centered Plans and include physical health recommendations • **State law 122C allows for communication between BHP and care managers, and between PCP and care managers without ROI

16. AccesCare of the Far West • Clinical Pharmacist: Caroline Lewis • Community Project Mgr: Sherry Dills (your main contact) • Nurse Care Managers: • Lead Beh Health Coord.: Courtney Cantrell

17. AccessCare of the Far WestContact Information

18. Care Management TeamRegional / Local Contacts Additional Care Management Staff