Best Practices for Integrated Care Teamscalduals.org/wp-content/uploads/2015/01/January-21-2015... · 2017-02-22 · Best Practices for Integrated Care Teams Cal MediConnect Providers

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Best Practices for Integrated Care Teams

Cal MediConnect Providers Summit

January 21, 2015

Moderator: Alexandra Kruse, Senior Program Officer, CHCS

Interdisciplinary Care Teams

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• Providers have a key role to play in the Interdisciplinary Care Team (ICT) for Cal MediConnect enrollees

• Primary interdisciplinary care team functions^

• Assessing the enrollee’s health status and needs, on an ongoing basis

• Care planning

• Facilitating and coordinating the delivery of services

• Facilitating transitions between institutions and the community

• Facilitating enrollee engagement in their care plan

• Will discuss health plan and provider experience with interdisciplinary care teams, as well as more broadly, other integrated care team arrangements

^ Cal MediConnect Care Coordination Fact Sheet available as part of the Physician’s Tooklit found

at http://www.calduals.org/physician-toolkit/

CareMore Model of Care

George Fields, D.O.Chief Medical Officer

CareMore Essentials

[email protected]

Phone: 866-646-3553

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Cal MediConnect Providers SummitJanuary 21, 2015

INTRODUCTION

• 40 years serving the underserved communities in So. Cal

• Largest independent Federally Qualified Health Center (FQHC)

• 43 sites in Los Angeles and Orange Counties

• Serves 150,000 families with 930,000 patient visits per year

• Provides healthcare from birth to senior years

• Contracts for Medi-Cal, Medicare, Commercial members

• Designation as Primary Care Medical Home (PCMH)

• 4 Star Rating

• Malcolm Baldridge Award

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INTRODUCTION (CONTINUED)

• Provides healthcare from birth to senior years

– Primary & Specialty Medical Care

– Dental Clinics

– Senior Long-Term care services and case management

– Program of All Inclusive Care for the Elderly (PACE)

– Disease Management

– Health Education

– Youth Services

– HIV/AIDS

– Substance Abuse treatment

• AltaMed very active in enrolling community into the ACA

• Enrolled most number of people into the Exchange & Expansion

• Honored to serve the Cal MediConnect members

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CAL MEDICONNECT (CMC)

• Preparing to serve dually eligible beneficiaries since 2012

• Began receiving membership June 2014 in Los Angeles

• High priority to integrate CMC members into our system

• Making certain member accurately tied to prior provider

• Continuity of Care is administered

• Emphasis on initial claims & health risk assessment (HRA) data

to prioritize outreach

• Individual Care Plans being created on all CMC members

• Initial Health Assessments being scheduled

• Interdisciplinary Care Teams scheduled with member/caregiver

• Care Coordination with DME, MSSP, SNF, Primary/Specialty

• Enterprise-wide meetings to monitor progress 14

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COORDINATED CARE TEAM

PATIENT CENTERED CARE

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COORDINATED CARE TEAM

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• ADDRESS REFERRAL ISSUES (MEMBER/PROVIDER)

• PROVIDE EDUCATIONAL MATERIALS• HELP MEMBERS NAVIGATE HEALTHCARE

SYSTEM• ONGOING FOLLOW UP WITH MEMBER

BASED ON RISK LEVEL AND MEMBER NEEDS

• LIAISON BETWEEN MEMBER AND PROVIDER

• DETERMINE HOME BASED CARE NEEDS• ASSIST WITH APPOINTMENT

• MEDICATION MANAGEMENT & EDUCATION

• ASSIST WITH NEEDS OF THE OLDER ADULT

• PROVIDE LINKAGE TO OTHER PROGRAM (DSM)

• LINKAGE BETWEEN HOSPITAL & OUTPATIENT PROVIDER

• TRANSITION CARE PLANNING• ASSIST WITH APPOINTMENT

SELF MANAGEMENT PLANNING

CARE PLANNINGINTERDISCIPLINARY CARE TEAM

COORDINATED CARE TEAM

SUCCESSES TO-DATE

• Created Coordinated Care Team to support the Cal

MediConnect effort

• Ability to use historical claims, pharmacy, TAR’s and Continuity

of Care data to start creating care plans even before HRA’s

come in (measuring heavy ER usage, inpatient stays, high risk

medications, etc.)

• In the absence of HRA’s and historical claims data, using risk

profile scores from the health plans as a means to stratify

members and prioritize outreach efforts and resources

• Using analytics and creating dashboard to measure # of

appointments being made, translation of appointments into

IHA’s, enforcing and measuring Model of Care (MOC)

requirements (HRA, ICP, ICT)18

SUCCESSES (CONTINUED)

• Using analytics to create a list of non-contracted providers with

whom Letter of Agreement (LOA’s) have to be established

because of historical utilization and COC requirements

• Proactive systems setup & automation allowed AltaMed to divide

the CMC population by region, by risk level (initial stratification),

monitor HRA status, measure MOC statistics, etc.

• Capitation payments to PCPs for both Medi-Cal and Medicare

payments is simpler

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OPPORTUNITIES TO IMPROVE

• Accurate member contact information

• Health Risk Assessments (HRA) for all members

• Standardizing HRA for all health plans

• Claims paid amount would further assist in stratifying members

• Prior member-provider relationship sometimes not considered

• Retention of members

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BEST PRACTICES

• Early planning and training modules for health care changes

• Hiring staff competent in key LTSS programs such as IHSS,

CBAS, MSSP, LTC and hiring Social Workers

• Strong Data Analytics to stratify, prioritize, monitor program

• Ensure Behavioral Health Vendor and PCP in ICT

• Ensure LTSS provider/caregiver in ICT

• Development of Coordinated Care Model to meet the needs of

vulnerable population

• Dedicated SNFist and narrow network of quality SNFs

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Joseph GarciaChief Operating OfficerCommunity Health Group

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San Diego Experience

Integrated Care Teams – Best Practices

Joseph Garcia - Chief Operating OfficerCommunity Health Group

January 21, 2015

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Questions and Discussion