Community Care of North Carolina
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The Case for Medical Homes and Community Networks “NC’s Approach to Healthcare” Webinar – National Partnership for Women & Families Denise Levis Hewson, RN, BSN, MSPH July 13th, 2010 Community Care of North Carolina Joins other community providers (hospitals, health departments and departments of social services) with primary care physicians Designated primary care medical home Creates community networks that assume responsibility for managing recipient care in concert with the PCP Community Care of North Carolina AccessCare Network Sites AccessCare Network Counties Access II Care of Western NC Access III of Lower Cape Fear Community Health Partners Northern Piedmont Community Care Carolina Collaborative Comm. Care Carolina Community Health Partnership Partnership for Health Management Central Piedmont Access II Comm. Care Partners of Gtr. Mecklenburg Southern Piedmont Community Care Plan Community Care of Wake and Johnston Counties Community Care Plan of Eastern NC Central Care Health Network Sandhills Community Care Network Community Care Networks Are Non-profit organizations Seek to incorporate all providers, including safety net providers Have Medical Management Committee oversight Receive $3.00 pm/pm from the State for most enrollees $8.00 pm/pm for the Aged, Blind and Disabled enrollees Hire care management staff to work with enrollees and PCPs Participating PCPs receive $2.50 pm/pm to provide a medical home and participate in Disease Management and Quality Improvement $5.00 pm/pm for Aged, Blind and Disabled NC Medicaid also pays the PCP “Fee For Service” @ 95% of Medicare Each CCNC Network Has: A Clinical Director A part-time physician who is well known in the community Meets with physicians to encourage CCNC participation Provides oversight for quality improvement in practices Serves on the Sate Clinical Directors Committee A Network Director who manages daily operations Care Managers to coordinate services for enrollees A PharmD to assist with Med Mgt. of high cost patients Psychiatrist to assist in mental health integration (summer 2010) Access III of the Lower Cape Fear, Inc. Organizational Chart Lydia Newman, MPP Executive Director Jim Jones, MD Medical Director Don Collins, CAE Chief Operating Officer Susan Martin HR & Technology Manager Angela Ives, RN Case Management Coordinator Program Director for Diabetes & GMV Randy Barrington, MBA Quality Improvement Coordinator Megan Rose, PharmD Pharmacy Coordinator Program Assistants Megan Marshall Melanie Melton Annamarie Atwood Office Coordinator Joelle Eddy Administrative Assistant Ada Atkinson, RN, BS Chronic Care Coordinator Aimee Donaton, MPH, RD, LDN, CDE Case Managers Regina Pool, RN Ruth Huggins, RN, BSN Fran Harris, RN, CCM Barbara Stern, RN, CDE Tina McPherson, RN Val Southern, RN, CCM Connie McMurray, RN, BS Mary Stephens, SW Kathy Reese, RN Marry Jarosz Bladen & Columbus Bladen County Brunswick County Brunswick County Columbus County Columbus County New Hanover County New Hanover County Onslow County Health Check Coordinator New Hanover County Case Managers Beverly Newton, RN, CCM Linda Dougherty, RN Elissa Hanson, MSW, LCSW Bobbi Kuhn, RN, Heather Lippincott, MSW,LCAS Roxanne Noble, RN, CCRC Pender County New Hanover County New Hanover County New Hanover County New Hanover County New Hanover County Community Care’s Chronic Care Program Managing Clinical Care (Spreading Best Practice) Clinical Directors Group I • Select targeted diseases/care processes • Review evidenced-based practice guidelines • Define the program • Establish program measures Local Medical Management Committee II III • Implement state-level initiatives • Develop local improvement initiatives PRACTICE A PRACTICE B PRACTICE C Care Managers and CCNC quality improvement staff support clinical management activities Current State-wide Disease & Care Management Initiatives Asthma Diabetes Pharmacy Management (PAL, Nursing Home Polypharmacy) Dental Screening and Fluoride Varnish Emergency Department Utilization Management Case Management of High Cost-High Risk Congestive Heart Failure Chronic Care Program – including Aged, Blind and Disabled Rapid Cycle Quality Improvement Chronic Care Program Components Enrollment/Outreach Screening/Assessment/Care Plan Risk Stratification/ Identify Target Population Patient Centered Medical Home Transitional Support Pharmacy Home – Medication Reconciliation, Polypharmacy & PolyPrescribing Care Management Mental Health Integration Informatics Center Self Management of Chronic Disease Program Components & Interventions Patient Centered Medical Home - Every enrollee has a patient centered medical home - Evidence based care is provided - Ensuring disease management of chronic illness(e) occur (diabetes, CHF, COPD, HTN, depression, etc.) - Participating actively in clinical performance improvement activities - Patient tracking and referrals - E-prescribing - Electronic health information Program Components & Interventions Transitional Support • Across providers and delivery settings • Partner with hospitals • Obtain real time data • Participate in discharge planning • Coordinate community resources and services • Face-to-face care management contact with high risk patients within 3 business days from discharge • Medication reconciliation • Follow-up visit with PCP and/or specialists Program Components & Interventions Pharmacy Home • Pharmacists integrated into networks to target high risk population • Focus on adherence, clinical alerts, therapeutic equivalents, and medication reconciliation at transitions of care • Feedback to care manager and PCP • Poly-pharmacy related – poor self- management of daily regimen and competing or interacting daily • Poly-prescriber related – prescriber often operating in an information vacuum Program Components & Interventions Care Management - Incorporating a standardized approach to care coordination and management priorities - Integrating targeted case management of high risk patients - Ensuring disease management - Generalist vs. Specialist Approach - Targeting interventions where they will have the greatest impact - Support patient self management Program Components & Interventions Mental Health Integration • • • • • • • Develop relationships and communication processes/tools Screening for and management of Depression Management of Depression Partner with Behavior Health Collaborate on Quadrant IV patient Co-location opportunities Psychiatrists at central office and at networks (summer 2010) 646 Demonstration Project 646 Counties Ashe Alleghany Surry Rockingham Stokes Caswell Warren Granville Vance Person Northampton Gates Hertford Halifax Watauga Wilkes Yadkin Bertie Orange Mitchell Franklin Forsyth Guilford Alamance Avery Caldwell Durham Nash Edgecombe Alexander Washington Dare Davie Madison Yancey Martin Tyrrell Davidson Iredell Wake Randolph Burke Wilson Buncombe McDowell Catawba Chatham Pitt Beaufort Rowan Hyde Haywood Johnston Greene Swain Rutherford Lincoln Lee Cabarrus Graham Montgomery Jackson Henderson Gaston Harnett Lenoir Polk Cleveland Stanly Wayne Craven Moore Pamlico Mecklenburg Cherokee Macon Transylvania Cumberland Clay Jones Richmond Hoke Sampson Union Anson Duplin Onslow Scotland Carteret Robeson Exempt Intervention Bladen Pender Columbus Holdouts Brunswick Updated: October 1, 2009 New Hanover KEY ELEMENTS OF NCCCN’s DEMONSTRATION During years one and two, NCCCN will manage approximately 30,000 dually-eligible beneficiaries who receive care from 198 practices in 26 counties. At the beginning of year three, an estimated 150,000 Medicare-only beneficiaries who will receive care from those practices will be added to the demonstration. During years three to five, NCCCN will manage an estimated 180,000 Medicare and dually-eligible beneficiaries. Payment to Support 646 Use the “one touch” rule – if a dual is touched by a participating practice, then CMS counts that person a “enrolled” Practices and networks will get the PMPM from the state for the enrolled duals Enrollment is voluntary, so practices and networks will still be managing those that have touched a practice but are not enrolled Straight Medicare not included until year 3 and goal for shared savings to fund the PMPM Shared Savings Finalizing methodology with CMS Will have a threshold savings, then 80/20 Details still being finalized Must achieve a percentage of improvement in quality metrics to receive financial savings Data/Informatics Use of claims-derived data for population management and care coordination Quality measurement with claims data and chart review data (Examples to follow) Chronic Care/ 646 Patient Database 80 data elements reported quarterly on ALL ABD recipients: Demographics Spending by category Utilization Diagnoses Use of ancillary services Priority scoring Provider Portal Patient Record: Care Team Summary Page Want to know more: www.communitycarenc.org Questions:
