RCCO and the Medical Home Concept

1. RCCO and the Medical Home Concept Molly Markert, Colorado Access RCCO Region 3 Contract Manager Devra Fregin, Director of Practice Management Kids First Health Care

2. Alphabet Soup • Welcome to the Accountable Care Collaborative (ACC) • The Accountable Care Collaborative (ACC) is a new Medicaid program to improve clients' health and reduce costs. • Medicaid clients in the ACC will receive the regular Medicaid benefit package, and will also belong to a "Regional Care Collaborative Organization" (RCCO). • Medicaid clients will also choose a Primary Care Medical Provider (PCMP). • What is a Regional Care Collaborative Organization (RCCO)? • The RCCO connects Medicaid clients to Medicaid providers and also helps Medicaid clients find community resources and social services in their area. • The RCCO helps providers to communicate with Medicaid clients and with each other, so Medicaid clients receive coordinated care. • A RCCO will also help Medicaid clients get the right care when they are returning home from the hospital or a nursing facility, by providing the support needed for a quick recovery. • A RCCO helps with other care transitions too, like moving from children’s health services to adult health services, or moving from a hospital to nursing care.

3. What is a Primary Care Medical Provider (PCMP)? • A primary care medical provider (PCMP) is a Medicaid client's main health care provider. • A PCMP is a Medicaid client's “medical home,” where he/she will get most of their health care. • When a Medicaid client needs specialist care, the PCMP will help him/her find the right specialist. All clients enrolled in the ACC have a PCMP. • What are the Goals of the RCCO Program? • By assisting Medicaid clients in getting connected to a PCMP as their Medical Home and by ensuring the medical, specialty, mental health care and other related services are well coordinated, clients’ experience in the health care system will improve. • Clients will be the primary “drivers” of their healthcare decisions, but will have the support and assistance they need to achieve their personal healthcare goals. • In addition, by having a primary source of medical care that attends to both sick care and wellness and prevention activities, the overall health of Medicaid clients will improve. • Finally, when clients are more satisfied and empowered in their healthcare decisions and overall health improves, the total cost of care is reduced.

4. Program Measures • Emergency Room Visits: • Medical care in an emergency room is costly, disruptive, and not always necessary • By helping Medicaid clients understand what alternatives they have for using the emergency room for non-emergent conditions, unnecessary use of emergency rooms will be reduced. • Inpatient Readmissions Within 30 Days: • Inpatient care is necessary for many healthcare conditions and circumstances, and as such is an essential component of the healthcare continuum. • However, rapid readmission to inpatient care can often be avoided if Medicaid clients get the assistance they need to ensure timely post-discharge after care with their PCMP, understand their discharge instructions and medications, and have adequate supports to make a successful and sustained transition out of the hospital. • High Cost Imaging: • This refers to costly diagnostic procedures such as MRIs and CT scans. • While these are valuable, necessary tools, they are often unnecessarily repeated when multiple providers are involved in a client’s care. • By ensuring better communication and coordination of care between providers, some of these duplicative services can be eliminated. • Well Child visits –added this year as a measure specific to pediatric and family practices

5. RCCO Regions

6. Benefits of being a PCMP in the RCCO Network • $3.00 PMPM • FFS Reimbursement • Incentive payment • Shared Savings • Data Analytics and Reporting Capabilities • Care Coordination and Medical Management • Practice Supports • Technical Supports

7. Responsibilities of being a PCMPin the RCCO Network • Adopt the tenets of being a medical home • Especially access criteria similar to all Medicaid • Promote quality health care • Coordinate care with specialists and referrals • Promotes partnership with patient and provider • Integrated with other needs • Decide care planning together • Consistent care geared to your past experiences • Provide sick and well care

8. It’s about Transformation! • Using data and analytics is new, scary, unique and extremely productive • Attention to cost drivers and incentives for improved care does influence results • Knowledge leads to empowerment for all • Collaborating across the region is new concept • Best practices are shared as they emerge • Clinical Transformation happens together

9. Care Coordination: The Clinic Perspective Kids First Health Care

10. Background on Kids First Health Care • Private, non-profit organization • 2 Community Pediatric Clinics and 4 School-Based Health Centers in Adams County • Our clinics are staffed with 1-2 CPNPs and 1-2 MAs • Pediatrician serves as our Medical Director (part-time) • Certified Children’s Medical Home • Participating in Accountable Care Collaborative (ACC) since February 2011 • Added Clinic Manager to take on staff supervision and project management (including the ACC) in August 2012

11. Managing Our Participation in the ACC • Attending monthly Regional Care Collaborative Organization (RCCO) meetings at Colorado Access • Now Quarterly • Many great resources and sharing of best practices • Getting to know Molly Markert and the expectations of being in the RCCO • Getting familiar with the SDAC Dashboard and the patients assigned to us • Clean up our patient list • Originally contained many adults • Sent forms to the state to remove the adults from our attribution • Process for removing adults is currently being revised • Time spent varies • In the beginning 6-8 hours per month in meetings and reviewing data • Now with Care Coordination/Delegation responsibilities more time is needed, but it is spread out among many staff members

12. Getting Delegated to take on the Care Coordination of our assigned patients • Complete Pre-Delegation Audit Tool • Review current policies and procedures • Revise/Create policies and procedures as necessary • Meet with representative from Colorado Access to review Pre-delegation audit tool and our policies and procedures • Colorado Children’s Healthcare Access Program (CCHAP) was available to help us with this process

13. Pre-Delegation Audit Tool • General Care Management Questions • Do you have a system to record care management notes, goals and progress? (EMR) • Do you have Care Management policies and procedures? • Regular communication • Follow-up procedures • Address barriers to receiving care • Cultural beliefs and values, and language barriers • Utilization of family or other support systems • Creation of Personal Health Record or patient web portal • System to stratify/tier levels of care management intervention

14. Care Management Staff Training Questions • Transitions of Care Questions • Quality Management/Quality Improvement Process • Internal and RCCO Communication • Departmental Focus Areas • Reducing inappropriate ER use • Preventing avoidable hospital re-admissions • Reducing duplicate, unnecessary, or inappropriate imaging • Increasing Well Child Checks

15. Care Coordination Practices • Review our monthly SDAC data (Example) • Stratify Patients (High Needs, Medium Needs, Low Needs) • High ER usage and high cost imaging services • Complex Chronic and Critical (ADHD, epilepsy, med changes) • At Risk, Simple Chronic and Stable (Asthma, Obesity, WCC) • Track patients monthly on Excel spreadsheet • Update patient charts with comments, tasks, care plans, etc. • Complete Monthly Metrics Form for Colorado Access • Attend monthly meetings with other delegated practices • Assign staff members to manage the care for these patients (Providers, MAs, Patient Navigators, etc.) • Part time patient navigator (Obesity grant from Kaiser) • Full time SBHC patient navigator (CDPHE Expansion Funding) • Money from our RCCO and increased visits helps sustain these positions

16. SDAC Data

17. Care Management Spreadsheet

18. Monthly Metrics • Assessment and Care Planning Process • Number of members with completed assessments • Number of members targeted for care coordination • Number of members with at least one intervention • Population Stratification Process • Number of RCCO members in each tier (High, Med, Low) • Transition of Care Process • Number of inpatient hospital discharges • Number of known inpatient hospital discharges that are eligible for transition of care • Number of members who participated in transition of care

19. Plan for ER reduction • Number of high ER utilizers identified • Description of interventions applied to high ER utilizers • Community Resource Referral Coordination • Define your community resource coordination process and the services/organizations with whom you coordinate (food, shelter, education, social needs) • Number of members referred to community resources • Integrated Care Coordination (across “medical neighborhood” and RCCOs) • Define relationships you have in place to facilitate care coordination process (Behavioral Health)

20. Transformation • Evaluate changes in data monthly (improvements, set-backs) • ER Visits • Re-Admits • High Cost Imaging • WCCs • Modify care coordination and data management practices • Merge data from previous months to reduce duplication efforts • Look into WCC coding practices • Engage staff in cycles of rapid improvement (PDSAs) • Educate the providers on who these patients are • Come up with action plans • Spread Best Practices

21. Monetary Benefit$ • PMPM payments for all attributed patients • $3 per month per patient • Based on current attribution • Incentive payments for performance on Key Performance Indicators (KPIs) • Decrease in ER visits, Re-admits, and High Cost Imaging • Increase in WCCs • Regional outcomes must be met in order to get $ • Paid out Quarterly • Max payment $1 per member per month • Delegated Care Management • $3.50 PMPM • Varies by Region

22. Questions?