Care Coordination: Coordinating Supports, Services, & Health Care

1. Care Coordination:Coordinating Supports, Services, &Health Care Jeff Capobianco, PhD, LLP National Council for Behavioral Health

2. Overview Health Home & Other National Drivers of Improved Care Coordination Defining Care Coordination “Health Home” Care Coordination: Lessons Learned from the Field

3. Healthcare System 2014

4. The Triple Aim Targets identified by Don Berwick (former director of the Center for Medicaid/care Services & Institute for Healthcare Improvement) that new approaches to healthcare services provision should aim to achieve: Improving the Health of Populations of People Bending the Cost Curve Improving the Patient’s Experience of Care Source: Berwick, Nolan, & Whittington (2008). The Triple Aim: Care, Health, & Cost. Health Affairs. vol. 27 no.3, 759-769.

5. The Affordable Care Act • Medicare Accountable Care Organizations • Health Insurance Exchanges (HIX)/Health Insurance Market Place • Health Information Exchanges (HIE) • Variety of State Based Waivers (e.g. Health Home)

6. So Many Terms so Little Time…

7. The Accountable Care Organization While extremely similar to the players in the alphabet soup of managed care players in the 1990s…ACOs differ significantly: • Accountability rests with the providers, rather than the health insurers • No health plan intermediary is required to contract with the provider organization • Great flexibility in their provider composition • Allow for payment under a fee-for-service arrangement • Are required to provide primary care • Have quality metrics tied to funding Source: ACOs and other options: A “how-to” manual for physicians navigating a post-health reform world 4th edition http://www.ama-assn.org/resources/doc/psa/physician-how-to-manual.pdf

8. Source: LeavittPartners.com

9. ACO Cost Findings

10. ACO Clinical Findings

11. Medicaid ACO Models Common Wealth Fund Medicaid ACO Learning Collaborative: Colorado Maine Massachusetts Minnesota New Jersey Oregon Vermont

12. States to Watch Re: I/DD HH Arizona, Michigan, & Wisconsin currently include people with I/DD in their managed long-term services and supports programs. Findings include improved access to long-term services and supports, improved coordination of care, and enhanced beneficiaries’ choice of providers. (Source: R. Gettings, “Reassessing the Impact of Managed Care in the Developmental Disabilities Sector,” The National Leadership Consortium on Developmental Disabilities, 2009 1(1). Available at: http://www.nasddds.org/pdf/PolicyInsightsBulletin(March2009).pdf.)

13. States to Watch Re: I/DD HH New York-- Developmental Disabilities Individualized Support &Care Coordination Organization (DISCO) New Jersey-- Arc of Monmouth became PCMH Rhode Island-- Children’s Focus Arkansas-- of course!! (Source: Structuring New Service Delivery Models for Individuals w/ I/DD. Lind & Archibald, CHCS Policy Brief; Feb. 2013)

14. What is a Health Home? • A State Waiver to drive System Level Transformation • Eligible individuals: • 2 chronic conditions; or • 1 chronic condition and is at risk of having a second chronic condition; or • 1 serious and persistent mental health condition

15. Person/Pt. Centered Medical Home: Key Components • Ongoing relationship with a medical provider who is trained to provide first contact, continuous, and comprehensive care • An informed and activated patient/person and support network • Whole person orientation • Care is co-managed by a team who collectively take responsibility to provide or arrange for care • Span of life care: Levels of care include acute, chronic, and preventive Source: http://www.integration.samhsa.gov/clinical-practice/CIHS_Health_Homes_Core_Clinical_Features.pd

16. Person/Pt. Centered Medical Home: Key Components • Care interfaces with family and community context as appropriate • Care is Coordinated • Quality and Safety are hallmarks • Robust Health Information Technology Capabilities • Enhanced Access to care is available • Payment appropriately recognizes the added value Source: http://www.integration.samhsa.gov/clinical-practice/CIHS_Health_Homes_Core_Clinical_Features.pd

17. Integrated Health “At the simplest level, integrated I/DD & physical health care occurs when specialty & primary care providers work together to address all the healthcare needs of people w/ I/DD. Integration can be bi-directional: either (1) specialty I/DD services introduced into primary care settings, or (2) primary health care introduced into specialty I/DD.” Source: Butler M, Kane RL, McAlpine D, Kathol, RG, Fu SS, Hagedorn H, Wilt TJ. Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 09- E003. Rockville, MD. Agency for Healthcare Research and Quality. October 2008.

19. Service Delivery and Payment Reform It’s about Inverting the Resource Allocation Triangleso that: • Inpatient and Institutional Care are limited • Chronic conditions are care coordinated in the community

21. Movement to Invest in BH BH is attractive to investors b/c: Growing Market: National expenditures on BH are expected to reach $239 billion in 2014, up from $121 billion in 2003 ( 7% compounding growth rate). Favorable Legislation: Includes ACA, Parity, Carve-in approaches, & states moving to Managed Medicaid. Diverse Payer Mix: Medicare, 3rd Party, Medicaid (seen as most risky) Attractive Financing Model: Compared to general acute care hospitals margins=mid-teens, inpatient behavioral healthcare margins = 20-40% for acute hospitalization & 15-25% for residential treatmentw/ maintenance at 2% of revenue. Niche Markets: BH with untapped “Downsize fitness” business models. Private equity investors accounting for roughly 30% of overall activity during 2010 &2011. (Source: Jon Hill; Triple-Tree.com)

22. Population Based Care… Jeffrey Brenner - COMPSTAT >> HEALTHSTAT in Camden NJ - Care managed 1% of 100,000 people that used 30% of costs Behavioral health identifies people who represent top 5% to 10% of high cost consumers with a MH/SUD diagnosis in a state/community

23. Specialty I/DD health niche: caring for complex, costly patients Here Health Affairs: VA Lewis, et al.“The Promise and Peril of Accountable Care for Vulnerable Populations: A Framework for Overcoming Obstacles.” 2012.

24. I/DD Providers are Ready! I/DD providers have been doing person centered complex care coordination for years!

25. However, We Must Improve Our Care Coordination!

26. Care Coordination “the deliberate organization of patient care activities between two or more participants involved in a person’s care to facilitate the appropriate delivery of health care services.” Source: McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7—Care Coordination. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; June 2007.

27. Care Coordination…a BIG Concept…

28. Perspectives on Care Coordination Person & Family • How easy is it for me to get the care I/my loved one needs? Healthcare Provider • How easy is it for me to do my work? System Representatives • How easy is it for me to know care of high quality and cost effective? Source: McDonald, Schultz E, Albin L, et al. Care Coordination Atlas Version 3. AHRQ Publication No. 11-0023-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2010.

29. Principles of Care Coordination • Person Centered • All Staff, Consumers & their Supports are Accountable • Population-focused • Outcome Driven- Measured

30. Principles of Care Coordination • Proactive, Planned, & Comprehensive • Emphasizes Cross-Organizational Relationships/Agreements & Connectivity • Equitable • Safe

31. Care Coor. Readiness Checklist Leadership Articulating Vision/Mission Access to Care Financing Health Information Tech./Data Management/Cont. Qual. Improvement Team Based Care Health Network Relationships Evidence Based Care Staff Training/Support Consumer & Family Inclusion

32. Leadership Simple clear articulation of the organization’s Vision for HH Robust Communication Plan Work Plan with Measurable Targets & Timelines Entrepreneurial Mindset

33. Access to Care Same Day/Next Day is becoming the Standard Centralized Scheduling Comprehensive PH/BH Screening Transportation Support Telemedicine Approaches Must know who isn’t coming to you for services

34. Financing Must understand how to back-into episode of care payment approaches Partner with Primary Care to share costs/increase efficiencies Find where you are loosing money (e.g., no shows, inefficient workflows, lack of prevention/early detection, lack measurement etc.)

35. HIT/DM/CQI Technology must support work flows (e.g., data based decision making, dashboards, etc.) What you don’t measure will hurt you If you only have paper use excel to begin managing your data Consider outsourcing HIT/DM or networking so can focus staffing up CQI

36. Team Based Care Defining appropriate team goals Clear role expectations for team members A flexible decision-making process The establishment of open communication patterns The ability of the team to “treat” itself Source: Leipzig, Hyer et al. (2002). Attitudes Toward Working on Interdisciplinary Healthcare Teams: A Comparison by Discipline J Am Geriatr Soc 50:1141–1148.

37. Health Network Partnerships Conduct a community assessment of social service and health care provider services Reach out to the providers you don’t know Develop stronger networks for those you do know to begin sharing information Target hospitals, ACO’s, and Fed. Qual. Health Center’s

38. Evidence Based Care I/DD providers must understand the EBP for screening/assessment and treatment of physical health conditions Assess the use of evidence based approaches to care provision (e.g., motivational interviewing, tobacco cessation, etc.) Use HIT to support tracking EBP fidelity

39. Staff Training/Support Staff want to know: What should I stop doing? What should I keep doing the same? What should I do differently? Seek out avenues for cross-training between PC and I/DD staff Target use of data to inform staff/teams about how they are coordinating care and Screening/monitoring of PH conditions

40. Consumer & Family Inclusion Consumers & Families are critical to team based care approach Must include consumers & family members in new policy/procedure development & work plan implementation Leverage consumer & family’s existing relationships with PC supports your staff may not have engaged

41. Remember Sometimes Progress is Hard to See Unless you Dig Below the Surface!

42. Some helpful links: • http://www.integration.samhsa.gov/ (Great resource on everything integration) • http://www.integratedcareresourcecenter.com/ (Website detailing what is happening with health reform in each state) • http://www.chcs.org/ (Website focused on publicly funded healthcare and the transformations underway) • http://www.h2rminutes.com/main.html (Updates on the ACA for professions—great site to sign up for email notices)

43. Care Coordination Resources: Reducing Care Fragmentation: A Toolkit for Coordinating Care. (Prepared by Group Health’s Mac Coll Institute for Healthcare Innovation, supported by The Commonwealth Fund), April 2011. Making care coordination a critical component of the pediatric healthcare system: A multidisciplinary framework. New York: The Commonwealth Fund; 2009 Care Coordination Atlas Version 3, AHRQ Publication No. 11-0023-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2010. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press. 2013

44. Bundled Payment Resources American Hospital Association: Issue Brief Moving Towards Bundled Payment http://www.aha.org/content/13/13jan-bundlingissbrief.pdf CMS Bundled Payments for Care Improvement: Learning & Resources Area http://innovation.cms.gov/initiatives/Bundled-Payments/learning-area.html Transitioning to Episode Based Care http://www.chqpr.org/downloads/TransitioningtoEpisodes.pdf

45. Health Home for I/DD Health Care for Individuals with Intellectual and Developmental Disabilities: An Integrated Health Home DD Model Kastner & Walsh

46. Thank You! Jeff Capobianco jeffc@thenationalcouncil.org 734.604.2591