Coordinated By:
Medical Neighborhood Learning Group Work Session July 6, 2016 Record of Learning Meeting Participants Jane Acri, Central Ohio Area Agency on Aging Stephanie Baker, Clintonville-Beechwold CRC Ambur Banner, Ohio Department of Health Kenton Beachy, Mental Health America of Franklin County Barbara Camfield, YMCA of Central Ohio Kristin Casper, Charitable Pharmacy of Central Ohio Dave Ciccone, United Way of Central Ohio Shawn Clark, Sunrise Senior Living Jimmie Davis, Franklin County Public Health Erica Drewry, Central Ohio Area Agency on Aging Maurice Elder, LifeCare Alliance Linda Gillespie, Central Ohio Area Agency on Aging Elio Harmon, Alliance Healthcare Partners Jeannette Harrison, National Alliance on Mental Illness Camerla Hartline, OhioHealth Physician Group Laura Hill, The Center for Balanced Living
Shanna Huber, Ripple Life Care Planning Liz Kitchen, Ohio Department of Health Reggie Lipscomb, Physician Care Connection David Maywhoor, UHCAN Ohio Dustin Mets, CompDrug Laura Moskow Sigal, Central Ohio Diabetes Association Meghan O’Brian, Franklin County Public Health Colleen O’Brien, The Ohio State University Wexner Medical Center Laura Poling, Charitable Pharmacy Zach Reat, Ohio Association of Foodbanks David Reierson, Care Coordination Network Safira Robinson, HandsOn Central Ohio Joey Schulte, HandsOn Central Ohio Staci Swenson, PrimaryOne Health Jennifer Tiedt, Central Ohio Area Agency on Aging
Welcome & Framing To view slides used during the session, please click here. Introduction to the Care Coordination Network Dave Ciccone & David Reierson, Care Coordination Network) The Care Coordination Network offers our community an integrated and comprehensive system that meets the holistic needs of residents in an efficient and organized manner. Using the nationally-recognized Pathways HUB model which helps people take coordinated, step-by-step action toward set objectives, Care Coordination Network provides: • A single point of contact for individuals and families managing multiple needs, • Standard, organized pathways for information flow and funding, • Clear direction and efficiencies for all involved, and • Accountability for outcomes.ng Results for Families, Community care coordinators within various organizations work directly with individuals and families to determine their needs, identify the appropriate service pathways and follow up regularly to ensure milestones along each pathway are completed. Care Coordination Network’s standard, organized pathways for information flow and funding bring increased efficiency to the process. Providers receive payment for services once a milestone is reached. Having one consistent point of support for individuals and families pursuing multiple pathways builds the relationships and rapport needed to help people achieve a better quality of life. If you are interested in learning more about the CCN, please contact David Reierson (david.reierson@uwcentralohio.org). Shape the future of the Accountable Care Coordination Learning Group As the medical neighborhood model has been spread throughout the Greater Columbus community it has become apparent that care coordination initiatives are being implemented by a variety or groups and organizations. In an effort to align the work that is taking place and foster a co-learning environment, partners of the Healthcare Collaborative of Greater Columbus have shown an interest in reframing the Medical Neighborhood Learning Group around Accountable Care Coordination. This new framing would enable a diverse group of leaders to share learning and best practices on the care coordination efforts being implemented in their area of Greater Columbus.
To help shape the future of this discussion, learning group participants were asked to review a framework that was drafted to help define accountable care coordination and provide their feedback.
Group Discussion Does the proposed framework represent a good place to start to describe accountable care coordination in our region? o Care coordination is about helping patients not fall through the cracks and addressing their eventual outcome (how to make sure connection was made) o Case Managemnt Society of America deifinition: A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individuals and family’s comprehensive health needs through communication and available resources to promote quality, cost effective outcomes. o Common risk assessment. o Financial – MACRA, MIPS, CPC+ o Finding a common conceptualization of care coordination could be incorporated as establishing baseline for group. o Gauging need for a pathway/evolution of pathways. o Good place to start. Need to identify how to get there. o Have to discuss payor impact. o How do you link outcome to intervention? How do we know that success is attributed to receiving a certain service, and not something else? o How does system analyize how the families are connected? o How to address education of coordinators across a diverse array of agencies and employee roles. o Licensed personel to assist and record o Network coordination – CliniSync/Epic/CCN o Outcome measures. o Quality of care and a consistent entry point should be added to the components. o Scattered/lack of details. Devil in details. Initiative overload. o Tech and resources need to be consistent but have the ability to adapt to various practices/providers/organizations. o Transition of care o Yes, but need to make sure that client/patient needs are clearly identified on the front end. o What is the measurement for success? Have we identified that, or did the client/patient? Based on this framework, what components would you like to explore in future learning group sessions? o Alleviation of root causes of requiring care coordination. (poverty, etc.) o Centralized coordinator for individuals across systems. o Client engagement. o Client engagement and education.
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Financial impact/payment reimbursement Helping partners move out of silos. Can help reduce redundancy. How one coordination service related to another one and how they are communicating with one another. Need for ongoing training. Network coordination Outcomes and measurement, but can’t proceed unless tools and infrastructure are mapped to work together. Physician practice education on what social service agencies can provide. Screening and assessment practices and tools as it is the main driver, if not the driver, of the other components. Tools and infrastructure What about groups/organizations that are not United Way funded?
Closing Results of the value survey administered at the conclusion of the session are listed below. Meeting Scheduled All sessions hosted at the Nationwide & Ohio Farm Bureau 4H Center from 8:30 – 10:00am September 7, November 2 www.hcgc.org/medical-neighborhood-learning-group/
Learning Session Value Survey Very High High Medium Low No
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What are the key reflections you are taking away from today’s session?
Additional preparation is needed to lead the conversation. Open discussion is less productive. Have slides ahead of time or email link. How are your target population (clients, patients, etc.) helping to guide this process? How can you invite them to the table? I think there needs to be better clarity around the different groups supported by HCGC. Perhaps an org chart type structure. I think no one knows which meetings to attend and how best to engage in these efforts and I’m afraid you are going to lose people to this very important effort if this is not clarified. More clarification on CliniSync vs. Care Coordination Network. Make CliniSync work first. More physician practice education and networking with social service organizations. Need small group work—network sessions. Perhaps it would be beneficial to invite organizations who have other referral tools to this conversation. Put speaker contact info on agenda.