Medical Neighborhood Learning Group
Today’s Agenda • Welcome & Framing
• Introduction to the Care Coordination Network • Shape the future of the Accountable Care Coordination Learning Group
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
Care Coordination Network (fka Franklin County Pathways Community HUB)
Aligning accountable care coordination Accountable Care Coordination Learning Group – July 6, 2016
Session Objectives Learning Session Objectives
WHY
Why do we need the Care Coordination Network in central Ohio?
WHAT
What future value can it add?
HOW
How does this model operate?
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Why do we need the Care Coordination Network 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 the Care Coordination Network in central Ohio?
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What future value can this model add?
FIND
PROVIDE
MEASURE 7
What future value can this model add?
FROM THIS ….
…TO THIS 8
How does the Care Coordination Network operate?
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Care Coordination Network •
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 data system
•
Support and assist care coordination agencies in quality improvement and quality assurance activities
•
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 Care Coordination Network
•
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 data system, Pathways Method, and community resources
Funders/Payers
•
Public-private entities establish contracts/ agreements with Care Coordination Network to support delivery of 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 Care Coordination Network operations
Using Data to Improve Results and Reduce Duplication
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What are your questions?
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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
The need to improve quality of care
The need to improve care coordination
Accountable Care Coordination Learning Group
CelebrateOne
Medical Neighborhood Impact on Chronic Conditions
Care Coordination Initiative
Accountable Health Communities
Purpose: To create a safe learning environment to advance accountable care coordination
Care Coordination Initiative
Task Force to Prevent Family Homelessness
Community Care Coordination Efforts Care Coordination Referral System
Care Coordination Network
Coordinated by:
Individual Organizational Initiatives
Care Coordination Initiative
Care Coordination Network &
Accountable Care Coordination Learning Group
Care Coordination Initiative Individual Organizational Initiatives
Medical Neighborhood Impact on Chronic Conditions
Purpose: To create a safe learning environment to advance accountable care coordination
Care Coordination Network
Care Coordination Initiative
Build Relationships: Strengthening the relationships between clinical and social service organizations
Task Force to Prevent Family Homelessness
Align Shared Infrastructure: Link/make sense of shared infrastructure being utilized in the region Reduce Variation: Adopt and spread resultsbased practices
CelebrateOne
Care Coordination Initiative
Accountable Health Communities
Care Coordination Referral System Care Coordination Network &
Accountable Care Coordination Learning Group
Components
Accountable Care Coordination Framework
Example
Workforce Development
Training and education of care coordinators
Tools & Infrastructure
Technology being implemented to streamline care coordination
Screening & Assessment
Practices being utilized to screen and assess individuals for health-related social needs
Client Engagement & Education
Techniques and resources being used to engage clients in the care coordination process
Outcomes & Measurement
How do we know if our care coordination efforts are having a positive impact?
Additional Components?
Group Discussion #1
Is this proposed framework a good place to start to describe accountable care coordination in our region?
Group Discussion #2
Based on this framework, what components would you like to explore first in future learning group sessions?