Care Coordination and Interoperable Health IT Systems

1. Care Coordination and Interoperable Health IT Systems Unit 1: Overview of Care Coordination Lecture c – Long Term Care Coordination This material (Comp 22 Unit 1) was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Overview of Care Coordination Lecture c – Learning Objectives • Objective 1: Define care coordination effectiveness (Lecture a) • Objective 2: Explain the purposes for care coordination (Lecture a) • Objective 3: Discuss various models of Care Coordination (Lecture b) • Objective 4: Compare care coordination roles and responsibilities in the post-Affordable Care Act models of care across the care continuum (Lecture b) • Objective 5: Discuss Specialty care coordination (Lecture c) • Objective 6: Discuss Long term care/post-acute care (Lecture c) • Objective 7: Identify stakeholders in care coordination (Lecture c)

3. CMS Accountable Care Organizations (ACOs) • Voluntary organization of multiple health care providers • Focused on chronically ill • Provide right care at the right time • Avoid unnecessary duplication of services • Prevent medical errors

4. ACO Programs at CMS • Medicare Shared Savings Program – fee-for-service • ACO Investment Model – testing pre-paid savings in rural and underserved areas • Comprehensive ESRD Care – for dialysis • Next Generation ACO Model – for experienced ACOs • Pioneer ACO Model – for organizations experienced in care coordination

5. ACO Goals • Implement new reimbursement methods • Align diverse stakeholders • Implement planned and coordinated care processes specialized for chronic conditions and preventative care

6. ACO Goals (Cont’d – 1) • Develop a clinical integration system • Understand, plan for and adopt risk-stratified care management • Use health IT effectively

7. Long-Term Care / Post – Acute Home-Based Chronic Care Model and the Integrated Care Model (ICM) by the Sutter Center for Integrated Care include: • Community-based care • Home Health • Custodial Care • Medical House Calls • Hospital at Home • Palliative, Hospice and Advanced Illness care

8. Long-Term Care/Post – Acute (Cont’d – 1) • Examples include: • Skilled nursing home facilities • Rehabilitation facilities • Home health and hospice • Care is ordered and referred by the PCP team leaders • Care coordination expands to multidisciplinary teams • Securely maintain and share pertinent patient health information

9. Long-Term Care/Post – Acute (Cont’d – 2) • Shared plans of care • The right combination of prescribed post-acute services including: • Skilled nursing • Rehabilitation • Therapies • Nutrition • Counseling • Household support

10. Long-Term Care/Post – Acute (Cont’d – 3) • Periodic assessment and review • Keeping care teams informed about changes • Addressing needs related to social determinants of health • Sharing patient information with care teams • Collaborating for self-care management

11. Care Coordination from Facilities to Home • Decreased length of hospital and facilities stays • Decrease in unnecessary readmissions • Increased interest in how care coordination can benefit patients and families • Home skilled nursing care or simple attendant household assistance in the home

12. Home Health Care • Home health care and hospice or palliative care services are positively related to: • Receipt of needed care • Information about medications • Equipment / supplies • Self-care

13. Home Health Care (Cont’d – 1) • Caregiver burden was inversely related to care coordination for receiving information • Recommendations includes: • More information is provided • More reassurance and emotional support • More household assistance

14. Stakeholders in Care Coordination • Sharing health information through improved technology • Participating as expanded team members of the patient-centered medical home team • Sharing decision-making • Data-driven management for coordinating care

15. Stakeholders in Care Coordination (Cont’d – 1) • Patients and families • Communities • Federal, state, and municipal governments • Consumers and consumer groups • Advocacy and public policy groups • Health care reimbursement entities and organizations • Health plans • Government plans • Employers • Purchasers

16. Stakeholders in Care Coordination (Cont’d - 2) • PCMH care teams and care coordinators • Home caregivers • Nursing and home attendant service providers • Care managers • Physicians • Medical neighborhood • Health information technology systems groups • Telehealth, telemedicine and virtual care groups

17. Patients and Families • The most invested stakeholders • No formal training in health care

18. Entities and Health Care Organizations • Responsible for reimbursement • Controlling and reducing the total cost of health care for an individual or population

19. Advocates and Policymakers • Eliminate barriers to better care coordination • Drive health system regulatory reform • Incorporate key features of care coordination: • PCMN • Accountable care organizations • Health IT systems • Payment reform services and programs

20. Employers and Purchasers • Redesigning benefits programs • Share best practices and resources based on successful models • Improve health care coordinationand systems technology

21. Unit 1: Overview of Care CoordinationSummary – Lecture c – Long-term Care Coordination • Care coordination requires collaboration and communication between the primary care physician team leader, care team, and the patient • In long-term care, teams are responsible for ongoing care coordination and securely maintaining and sharing pertinent patient health information • There are variety of stakeholders in care coordination and patients are the most important

22. Unit 1 Summary: Overview of Care Coordination • Care coordination requires collaboration and communication between the primary care physician team leader, care team, and the patient • There are various post-Affordable Care Act models of care coordination across the care continuum • Patients are the most important stakeholders in care coordination

23. Unit 1: Overview of Care Coordination References – Lecture c References Sutter Center for Integrated Care. (2013). The Integrated Care Model (ICM). Retrieved 8 March 2016, from http://www.suttercenterforintegratedcare.org/ourmodel/

24. Unit 1: Overview of Care CoordinationLecture c – Long-term Care Coordination This material was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006.