AN EVOLVING SUCCESS STORY

1. THE INTEGRATION OF CARE COORDINATION: AN EVOLVING SUCCESS STORY

2. Trillium Community Health Plan (TCHP) • Began 35+ years ago as an ‘Independent Practice Association’ (IPA) for Lane County physicians • Grew to become ‘Lane Independent Practice Association’ (LIPA) to provide management of the Medicaid State Health Plan, now with 58,000 members • Continued growth resulted in formation of ’Trillium Community Health Plan’; developed to serve the Medicare eligible members in Lane County; currently with 3,500 members • Added a small membership of 150 with the Healthy Kids program • Integrated Medical and Behavioral Health services January, 2012 • Awarded CCO status by State in August, 2012 and combined all lines of business under Trillium Community Health Plan name

3. 2012 3 RN Care Coordinators & 3 Care Coordination Assistants working together to provide very high- level/high-touch care coordination services for: 3200 Medicare/Medicaid members 300 Medicare Advantage members 3 RN Exceptional-Needs Care Coordinators for: 65,000 Medicaid members

4. August 2012 The birth of the Trillium Coordinated Care Organization

5. December 2012 Integration brings together physical healthcare coordination and behavioral healthcare coordination staff into a cohesive, functional team.

6. January 2013 Integration of Community Health Workers into the Care Coordination Team begins. Lane United CareConnect (LUCC) and Trillium Community Health Plan (TCHP) partnered together in providing additional care coordination services within the Trillium Coordinated Care Organization (CCO)

7. Whoare the Community Health Workers? • Formerly, employees of Lane United CareConnect (LUCC); now employees of Trillium • Dedicated people with a desire to help improve healthcare in Lane County • Specially trained to provide a unique service to the Medicaid, Medicare, & dual-eligible members of our CCO community

8. Community Health Workers

9. September 2013 Changed our model of CC to multi-level care coordination teams working together with all Medicaid, Medicare, and Medicaid/Medicare members: • RN Care Coordinators • Care Coordinators • Behavioral Health Care Coordinators • Medical Social Worker • Community Health Workers

10. So What’s Next ??? • Development and deployment of community-wide consistency with THW education and scope of practice • Metrics and evaluation of current CHW program • Expansion of Perinatal Program to include greater integration of CHWs • Involvement of CHWs with high-risk cardiac members • Involvement of CHWs in Readmissions Program • Integration of CHWs into ED transitions

11. Recently restructured Care Coordination Teams are now working together with their groups of specific Primary Care Clinics to: • Implement the movement of communication of CC information to & from the Interdisciplinary Care Team (ICT) via our new web-based communication tool (CareTeamConnect). • Proactively coordinate care based on member’s level of risk. • Actively enroll identified members into special Care Programs for additional Disease Management.

12. The Trillium Care Coordination Team

13. Coordination of Care for Positive Health Outcomes

14. What Is Care Coordination? Trillium’s Definition of Coordination of Care: Care Coordination is a community-wide team based approach to address the healthcare needs of the Trillium membership. Care Coordination incorporates physical health, behavioral health and community-based services, providers, and practitioners, to identify needs and ensure the provision of the right care at the right time, for our members.

15. Trillium Community Health Care Model External Provider makes referral of patient to Trillium Care Coordination. Provider/TCHP identifies patient with complex needs. • Internal • Hot Spot List • Risk Stratification • Hospital Readmissions • CC/UM Identification referrals • Trillium Care Coordination triages patient referral to determine if CHW is needed. • Trillium Care Coordination Team identified to work with CHW and patient • LUCC receives triaged CHW referrals • Care Plan issues for CHW assistance are identified on referral • Trillium Care Coordination Team meets every 2 weeks with LUCC CHWs • Ongoing training • Complex Case Review • Updates on referred patients • Continued ongoing communication

16. External Referral Form Service Provider initiates a referral of their patient to the Trillium Care Coordination Team

18. Trillium Behavioral Health, Medical, and CHW Care Coordination Team Meeting

19. Special Care Programs • Cardiac/Million Hearts • Tobacco Cessation in Pregnancy • Diabetes Disease Management • COPD/Asthma Disease Management • Pilot project-’Top 40’ Heart Failure Disease Management • High-Risk IP Discharge • Restructure of Complex Case Management into stand-alone teams

20. Analytics Summary

21. Trillium ‘All Care’ Care Coordination meetings bring the entire team together to coordinate ALL care for the member: • Physical Health CC • Behavioral Health CC • Community Health Workers • Utilization Review Nurses • Pharmacy • DME • ISNP CC

22. Next Steps… • Last month we held our 1st Community-wide Care Coordination Meeting to introduce the Trillium CC Teams to their community counter-parts. • We are hopeful through shared experiences to learn more about creating Community Care Coordination Meetings that are successful for all.

23. Questions?

24. THANK YOU FOR YOUR TIME AND ATTENTION Dr Holly Jo Hodges Medical Director, Trillium Community Health Plan 541-431-1950