Care Coordination Network (previously Franklin County Pathways Community HUB)
Accountable care coordination to align health and social services Regional Learning Session – August 19, 2016
Session Objectives Learning Session Objectives What are we working on? What are we learning? What collective knowledge can help shape our work?
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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?
FROM THIS ….
…TO THIS 4
What are we working on? Pathways: our care coordination approach
Screening determines client is pregnant and without prenatal services
FIND
Home visit by care coordinator to assess client and family needs
Comprehensive assessment identifies health and social needs: • First trimester; no OB • Food insecure • Unemployed • Child not enrolled in early care • Immunization record not current
Pregnancy pathway Social service pathway Adult education pathway Developmental referral pathway
Care coordinator checks in regularly to verify family is connected to services
Family receives services and issues contributing to elevated risk are managed
• Risk reduced • Full term delivery • Healthy birth weight • Child on track developmentally
Immunization referral pathway
PROVIDE
MEASURE 5
What are we working on?
CCN infrastructure development • Public-Private Advisory board • 3 FT Staff • Policy/procedure
Current Funders • OCMH – infant mortality • Healthier Buckeye – workforce • United Way – poverty reduction
CCA Partners • Physicians CareConnection • Community Dev. for All People • Columbus/FC Kids
Client Volume (Q4 2015 – Q2 2016) • Adult - 98 • Pregnant – 60 • Pediatric – 1,183
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From a Client Perspective: housing instability FIND: Engage with single care coordinator
PROVIDE: Establish plan of care
Father • 31 yr old AA male • Unemployed • Alcohol abuse
Job Training Referral
Enrollment in workforce dev. program
Mother • 27 yr old, AA female • Employed PT • Diabetic: A1C-8.1
Beh. Health Referral
Substance abuse counseling
Child • 3 yr old • Developmental delays
Health Ins. Referral
Family Risk Assessment Needs Job training Medical referral Medication education Medication management Substance abuse counseling Food access/nutrition education • Insurance education/ enrollment • Developmental screening/ referral
Factor Reduction
Housing Stability Indicators On time rent payments
Medicaid enrollment
Medical Referral
Primary care appointment
Dev. Referral
Enrollment in Head Start early care
Education
Not past due on rent Not past due on utilities
Care Coordinator • • • • • •
MEASURE: Risk
Nutrition/ Diabetes Education
≤ 30% of income devoted to housing
What are we learning? Pregnant Clients by Race
6%
Pregnant Clients by Income
Black or African American White Mexican, Hispanic, Latino or Spanish Other
8%
20%
12%
4%
$0 - $5,000 $5,001 - $20,000 $20,001 - $50,000 Refused
20% 64%
66%
Pregnant Clients by Age 10% 6% 20%
50 Pregnant Client Households
<19 20-24 25-34 35-44
64%
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What are we learning? Housing
Other
Smoking Cessation Medication Assessment
Pathways
Immunization Screening Medical Referral Open Incomplete Completed
Education Medical Home
Social Service Pathways
Health Insurance Housing Assistance
Food Assistance/WIC Open Incomplete Completed
Food Assistance
Financial Assistance
Postpartum Cribs for Kids Social Service Referral Clothing Assistance Pregnancy 0 0
5
10 15 20 25 30 35
1
2
3
4
5
6
7
# of Pathways
# of Pathways
50 Pregnant Client Households 9
What are we learning? Households by Race 15% 4% 52%
Households by Income
Black or African American White Mexican, Hispanic, Latino or Spanish Other
29%
2%
$0 - $5,000 $5,001 - $15,000 $15,001 - $25,000 $25,001 - $50,000 More than $50,001 Refused or Don't Know
8%
14%
38%
15% 23%
Households by Oldest Member Age
9%
25%
6% <24 25-34 35-54 >55 60%
150 Adult & Pediatric Client Households 10
What are we learning? Medication Assistance Smoking Cessation Vision
Legal Assistance Pregnancy Job/Employment Assistance Postpartum
Speech and language
Insurance Assistance Medication Management
Food Assistance Medical Referral / WIC Food Assistance Medical Home Financial Assistance Lead Family Assistance Housing Education Assistance Health Insurance Domestic Violence Assistance Family Planning Cribs for Kids Employment Clothing/Baby Items Education Clothing Assistance Behavioral Child Assistance Adult Education 0 10 20 30 40 50 60 70 0 10 20 30 40 50 60 70 # of Pathways # of Pathways
Specialty medical care Medical Referral Pathways
Pathways Social Service Pathways
Housing Assistance Medication Assessment
Primary care
Open Open Incompleted Incompleted Completed Completed
Pharmacy
Open Incompleted Completed
Other
Mental Health Family planning Dental 0
5
10
15
20
25
# of Pathways
150 Adult & Pediatric Client Households 11
What collective knowledge can help shape our work? • What are you seeing here that aligns with your priorities? • What are the ways this work can help improve our community’s level of accountable care coordination? • What are the challenges and opportunities of taking a more integrated approach to care coordination?
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