May 2016
Medical Neighborhood Referral Infrastructure Project
In-Person Work Session
www.hcgc.org
Today’s Agenda
• Welcome and Introductions • Aligning Shared Referral Infrastructure
• Small Group Work Session www.hcgc.org
Align Shared Infrastructure
Organizations Exchanging Referrals • Alliance Healthcare Partners • Central Ohio Area Agency on Aging • Central Ohio Diabetes Association • Central Ohio Primary Care • Charitable Pharmacy of Central Ohio • Clintonville-Beechwold Community Resource Center • Equitas Health (formerly ARC Ohio) • Helping Hands Health and Wellness Center
• LifeCare Alliance • Lower Lights Christian Health Center • Metropolitan Family Care • Mount Carmel Health Partners • Physicians CareConnection • PrimaryOne Health • Ripple Life Care Planning • Southeast, Inc. • Syntero • The Breathing Association • YMCA of Central Ohio
Align Shared Infrastructure
Organizations Committed to Participate •
Caliber Patient Care
•
Franklin County Office on Aging
•
Health & Wellness Pharmacy
•
Kroger Pharmacy
•
Mount Carmel Medical Group
•
National Church Residences
www.hcgc.org
Medical Neighborhood
Purpose: Advancing accountable care coordination across clinical and social service organizations • Relationships: Strengthening the relationships between clinical and social service organizations • Reduce Variation: Adopt and spread resultsbased practices • Align Shared Infrastructure: Link/make sense of shared infrastructure being utilized in the region www.hcgc.org
Align Shared Infrastructure Healthcare Provider
• Creates buffer between CliniSync and non-covered entities
Social Service Social Service
CliniSync Referral Tool
Healthcare Provider
• May be able to replicate approach with other care coordination efforts
Mid-Ohio Foodbank
Local Food Pantry
PantryTrak
Local Food Pantry *Data bridge in development
Local Food Pantry
Local Food Pantry
Franklin County Pathways Community HUB Aligning accountable care coordination Learning Session – May 20, 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?
10
What future value can this model add?
FIND
PROVIDE
MEASURE 11
What future value can this model add?
FROM THIS ….
…TO THIS 12
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
•
Provide data processing, reporting, invoicing, and collection tools
•
Provide or arrange training for community care coordinators in Pathways Method and use of Hub data system
•
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
•
Provide care coordination services to clients using community care coordinators trained and supervised in Pathways Method
•
Perform mutually agreed upon supervision, quality improvement, and quality assurance activities
•
Ensure sufficient education and training to community care coordinators on HUB’s data system, Pathways Method, and community resources
Funders/Payers
•
Public-private entities establish contracts/ agreements with HUB to support delivery of care coordination services to specific populations using accountable payment arrangements
•
Contract terms structured based on payments to care coordination agencies for qualifying activities and outcomes
•
Payments will directly support care coordination activities and be reinvested in support of HUB operations
Using Data to Improve Results and Reduce Duplication
17
What are your questions?
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Small Group Work Session #1
Question 1: What lessons have you learned from implementing/using the shared referral infrastructure? Question 2: What best practices has your organization identified that have made the shared referral infrastructure more effective?
www.hcgc.org
Small Group Work Session #2
What activities could HCGC, CliniSync and project partners do to improve the referral network?
www.hcgc.org