PowerPoint Presentation - Slide 1

Community Care of
North Carolina
Child Health Accountable Care Collaborative
Key Goals
 Improve access to, quality of, and
coordination of care
 By doing so, decrease the cost of care.
Community Care of NC
 Statewide primary care medical home & care management system
 Rests on foundation of Carolina Access Medicaid in which
Medicaid patients are linked to a primary care home
 Provides resources to improve access to, quality of and
coordination of care across the different segments of the local
health care system and decrease cost of care
 Private-public partnership (all savings stay in NC)
 Provides ready access to data
 Community based, locally driven, provider led
Local Networks
 14 local Networks across all 100 NC
counties with more than 4500 Primary
Care Physicians (1360 medical homes)
 Over 1.4 million Medicaid enrollees,
including dual Medicare/Medicaid and
Health Choice enrollees
Local Networks
 Are non-profit organizations
 Provide resources to primary care homes to better manage
Medicaid population
 Join public and private sector primary care homes with other
segments of the health care system (e.g. hospitals, health
departments, mental health agencies, social services) to
create local systems of care
 Utilize local multi-disciplinary RN and SW care managers,
pharmacists, psychiatrists, obstetricians, medical directors
 Pilot potential solutions, share best practices
 Are capable of and accountable for managing recipient care
Main Program Activities
 Chronic Disease Management Initiatives (e.g. Asthma, Diabetes)
 Chronic Care Initiative
 Hospital Transition Care
 Quality Improvement Initiatives
 Emergency Department Utilization
 Chronic Pain Initiative
 Integration of Physical and Mental Health
 Prevention Initiatives
 Pharmacy Initiatives
 Palliative Care
 Access to Primary Care
 Support of IT Initiatives
 High Risk Pregnancy Care Management
Key program Asset- Access to data
Informatics Center
 Medicaid claims data
 Utilization (ED, Hospitalizations)
 Providers (Primary Care, Mental Health, Specialists)
 Diagnoses
 Medications
 Labs
 Costs
 Individual and Population Level Care Alerts
 Reports on high-opportunity patients
 Quality Measurement and Feedback Review System
Key program Asset- Access to data
Real Time Data
 Hospitalizations
 ED visits
 Provider Referrals
Link to local health care system and
community resources
Multidisciplinary management
QI Support
Primary Care
Public Health
Primary Care
Social Services
Child Health Accountable Care
Collaborative (CHACC)
CMS Innovations Project
Partnership of Community Care of North Carolina and Children’s Health Care Providers
 3 year Cooperative Agreement from the CMS
Innovations Center to Community Care of North
Carolina--July 1, 2012- June 1, 2015
 Partnership of CCNC with Children’s Primary Care
and Specialty Care Providers; and the Academic
Medical Centers and Children’s Tertiary Care
Hospitals to improve the health of NC children who
have complex and chronic illness
Child Health Accountable Care
Collaborative (CHACC)
Partnership with North Carolina’s Children’s Healthcare Providers, North Carolina’s Academic
Medical Centers and Tertiary Medical Centers
Community Care of North
Project Director
Steve Wegner, MD
Medical Directors
Elizabeth Tilson, MD (CCNC Networks)
David Tayloe, MD (Primary Care)
Alan Stiles, MD (Pediatric Subspecialists/Hospitals)
CHACC Integration Workgroup
Program Director
Sherri Branski, RN, MSN, CCM
Lynn Guerrant, RN, MS
CCNC Networks/Primary Care Providers
Medical Home
CCNC Network Care Managers
Pediatric Subspecialists/AMCs/Tertiary
Children’s Hospitals
CHACC Lead Care Managers, Care
Managers, and Patient Coordinators
Program Goals
 Improve the health of NC children with complex chronic illnesses
through improved value of care.
 Engage primary care providers and pediatric subspecialists
across the state to share responsibility and accountability for
pediatric primary, subspecialty, and hospital care.
 Jointly develop and utilize evidence based guidelines of care for
pediatric chronic illnesses with pediatric subspecialists and
primary care physicians and actively engage in co-management
of these children.
 Provide active care management to children under the care of
pediatric subspecialists through embedded care managers and
patient coordinators at tertiary hospitals and provide a warm
hand off to CCNC network care managers.
Children with complex, chronic
CCNC Networks--Medical
Home/Primary Care Providers
CCNC Care Managers
Pediatric Subspecialists/AMCs/Tertiary
Children’s Hospitals
CHACC Care Manager
Patient Coordinators
Cost Savings Approaches
 Reduce hospitalizations through co-management and active
monitoring of disease processes
 Improve primary and preventive care for children with chronic
illnesses by providing this care in a medical home
 Reduce utilization of emergency services and pediatric
subspecialists for acute common illnesses for these children
 Reduce duplication of laboratory and medical studies through
streamlined communication between primary care providers and
pediatric subspecialists
 Reduce pharmacy costs through formulary utilization and evidence
based care
 Operations plan submitted to CMS, August 8, 2012
 Anticipate CMS approval by September 10, 2012
 Convene a CHACC Integration Workgroup August 2012
 Information sessions and discussion at the NC Pediatric Society
Meeting September 2012
 Refine target population for intervention August to December,
 Hiring and training of care managers and patient coordinators
September 2012 to January 2013
 September 2012 to June 2013 Consensus Sessions of PCPs
and Subspecialists
The Role of the General Pediatrician
David T. Tayloe, Jr., MD, FAAP
Children and Youth with Special
Health Care Needs (CYSHCN)
 Registry of Patients
 Care Plans
 Subspecialist Care Coordination
 Primary Care Physician Care Coordination
 Community Partners
 Family Involvement
Goldsboro Pediatrics
 15 pediatricians, 7 nurse practitioners, a physician
assistant, 2 behavioral health professionals, 1
lactation consultant
 4 offices serving children in 7 counties
 Electronic Health Record System
 2 Community Care of NC AccessCare staff
 Community Hospital with Level 2 Neonatal Unit
Innovative Approaches
 Children and Youth with Special Health Care Needs
in Wayne County
 Steering Committee of Family Members of CYSHCN
and Community Partners
 Goldsboro Pediatrics electronic health record system
(secure intranet)
 Registry and HIPAA-compliant /FERPA-compliant
family consent procedures
Wayne Pediatric CME Series
 Category I CME Sessions co-sponsored by the Office
of CME at the Brody School of Medicine and
Goldsboro Pediatrics
 Meets at 7 AM in the private dining area of the
hospital cafeteria most every Tuesday morning
 Community Partners invited to attend sessions
Wayne Initiative for School
Health (WISH)
 Goldsboro Pediatrics is the medical home for the
students enrolled in the six school-based health
centers of WISH
 Nurse Practitioner and Physician Assistant, with the
help of RN’s, clerical staff, Registered Dietitians,
behavioral health professionals provide
comprehensive care for many at-risk middle/high
school students in Wayne County
Community Care of NC
 Care Coordinator and Patient Navigator are based in
the main office of Goldsboro Pediatrics
 CCNC staff attend CME sessions of the Wayne
Pediatric CME Series
 CCNC staff work closely with Community Partners
4% of Children
 Need continuous care by pediatric subspecialists
 Should have care plans/passports developed by their
subspecialist teams
 Need multiple services at the community level
 Need 24/7 access to a physician who has access to
the medical records of the child
Quality of Care for Children with
Complex Medical Conditions
 Guidelines and care plans/passports developed by
 Electronic communication involving tertiary center
specialists and community based generalists
 Regular visits with subspecialists and primary care
 Family input/electronic communication with
 Community partner collaboration coordinated by the
community-based medical home
Cost-effectiveness of Care for
Children with Complex Conditions
 24/7 access to subspecialist and generalist
 Avoid unnecessary expensive medications and
 Avoid unnecessary hospital emergency department
 Avoid unnecessary hospital admissions
Shortage of Pediatric
 Complex children need a lot of time from their
pediatric subspecialists
 NC has shortages of most categories of pediatric
 If these subspecialists are to maximize their time with
complex children, general pediatricians must do their
part to minimize unnecessary referrals to
David T. Tayloe, Jr., MD, FAAP
 Goldsboro Pediatrics
2706 Medical Office Place
Goldsboro, NC 27534
fax 919-580-1017
[email protected]
“The project described was supported by Funding Opportunity Number
CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services,
Center for Medicare and Medicaid Innovation.”
“Its contents are solely the responsibility of the authors and do not
necessarily represent the official views of HHS or any of its agencies.”
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