Community Care of North Carolina

Child Health Accountable Care Collaborative (CHACC)

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 dataInformatics 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 dataReal Time Data

Hospitalizations

ED visits

Provider Referrals

Patient

Primary Care Home

Multidisciplinary management support

QI Support

Link to local health care system and community resources

Patient

Primary Care Home

Hospital

Behavioral Health

~Specialists~

Public Health

Social Services

Community Resources

Child Health Accountable Care Collaborative (CHACC)CMS Innovations Project

Partnership of Community Care of North Carolina and Children’s Health Care Providers

CHACC

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 Carolina

CHACC

Project Director Steve Wegner, MD

Medical DirectorsElizabeth Tilson, MD (CCNC Networks) David Tayloe, MD (Primary

Care) Alan Stiles, MD (Pediatric Subspecialists/Hospitals)

CHACC Integration Workgroup

Program DirectorSherri Branski, RN, MSN, CCM Lynn Guerrant, RN, MS

CCNC Networks/Primary Care ProvidersMedical 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.

CHACC

CHACC Care ManagerCCNC Care Managers

Patient Coordinators

CCNC Networks--Medical Home/Primary Care Providers

Pediatric Subspecialists/AMCs/Tertiary Children’s Hospitals

Children with complex, chronic Illnesses

Co-management

Specialty CarePrim

ary C

are

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

Timeline

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,

2012 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 subspecialists

Electronic communication involving tertiary center specialists and community based generalists

Regular visits with subspecialists and primary care physicians

Family input/electronic communication with physicians

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 physicians

Avoid unnecessary expensive medications and therapies

Avoid unnecessary hospital emergency department visits

Avoid unnecessary hospital admissions

Shortage of Pediatric Subspecialists Complex children need a lot of time from their

pediatric subspecialists NC has shortages of most categories of pediatric

subspecialists If these subspecialists are to maximize their time with

complex children, general pediatricians must do their part to minimize unnecessary referrals to subspecialists

David T. Tayloe, Jr., MD, FAAP Goldsboro Pediatrics

2706 Medical Office Place

Goldsboro, NC 27534

919-734-4736

fax 919-580-1017

dtayloe@aap.org

“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.”