Franklin County Pathways Community HUB Aligning performance for results-based health and social services Quarterly Learning Session – April 8, 2016
Session Objectives Learning Session Objectives
WHY
Why do we need a Pathways Community HUB in central Ohio?
WHAT
What future value can it add?
HOW
How does a Pathways Community HUB operate?
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Why do we need a Pathways Community HUB in central Ohio? People in need face complex and interconnected issues, often requiring them to seek help from multiple sources
Health and social service providers recognize clients’ multiple needs and often coordinate referrals, but varying approaches and limited resources affect results
Funders/payers question whether their dollars are achieving the results they seek or if they’re paying for something that could have been prevented
Our community continues to have 1 in 5 people living poverty, and 1 in 3 struggling to meet basic needs
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Why do we need a Pathways Community HUB in central Ohio?
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What future value can this model add?
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What future value can this model add?
FIND
PROVIDE
MEASURE 6
How does a Pathways Community HUB operate?
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HUB •
Administrative and information technology infrastructure that provides tools, standards, and resources to operate model
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Provide data processing, reporting, invoicing, and collection tools
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Provide or arrange training for community care coordinators in Pathways Method and use of Hub data system
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Support and assist care coordination agencies in quality improvement and quality assurance activities
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Maintain all client data in compliance with applicable requirements of HIPAA, HITECH, and other regulations
Care Coordination Agencies (CCAs) •
Establish contract and business associate agreement with HUB
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Provide care coordination services to clients using community care coordinators trained and supervised in Pathways Method
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Perform mutually agreed upon supervision, quality improvement, and quality assurance activities
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Ensure sufficient education and training to community care coordinators on HUB’s data system, Pathways Method, and community resources
Community Care Coordinators (CCCs) •
Individuals trained, supported, and responsible for delivering care coordination services
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Employed by community based agencies contracting with HUB
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Work with client on care coordination plan and monitor progress to goals and priorities using Pathways method
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Provide client referrals and resources to additional services
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Maintain proper documentation of services provided and progress made in implementation of care coordination plan
Funders/Payers
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Public-private entities establish contracts/ agreements with HUB to support delivery of care coordination services to specific populations using accountable payment arrangements
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Contract terms structured based on payments to care coordination agencies for qualifying activities and outcomes
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Payments will directly support care coordination activities and be reinvested in support of HUB operations
How it works FIND: Initial Checklist – Captures
PROVIDE: Pathways identified and
Comprehensive Risk Issues Patient with Diabetes
• • • •
initiated
Medical Referral Medical Referral Medical Referral
Mental Health Appt.
52 yr old, AA female Medicaid Food Svc. Employee Diabetic: A1C-8.1
Social Service
Furniture Bank
Social Service
Food Pantry
Care Coordinator
Risk Assessment Needs Eye Exam Foot Exam Depression Furniture (was homeless) Food Access/Nutrition Education • Medication Education • Insurance Education
Eye Appointment Podiatry Appointment
Care Coordinator • • • • •
MEASURE: Risk Factor Reduction
Education
Diabetes Education – Medication Adherence
Education
Nutrition – Fruits and Vegetables
Increased patient show rates for appointments Increase in Clinical Outcomes Measures 3/2015 A1C -8.1 6/15 A1C – 7.1 7/2015 A1C - 6 Reduction of barriers for social determinants of health to care for patients Increased patient compliance in the management of their condition 9lb weight loss Medication Adherence Better Nutrition Increased access to resources for patients
Using Data to Improve Results and Reduce Duplication
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What are your questions?
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