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RCCO and the Medical Home Concept Molly Markert, Colorado Access RCCO Region 3 Contract Manager Devra Fregin, Director of Practice Management Kids First Health Care

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Alphabet Soup Welcome to the Accountable Care Collaborative (ACC) The Accountable Care Collaborative (ACC) is a new Medicaid program to improve clients' health and reduce costs. Medicaid clients in the ACC will receive the regular Medicaid benefit package, and will also belong to a "Regional Care Collaborative Organization" (RCCO). Medicaid clients will also choose a Primary Care Medical Provider (PCMP). What is a Regional Care Collaborative Organization (RCCO)? The RCCO connects Medicaid clients to Medicaid providers and also helps Medicaid clients find community resources and social services in their area. The RCCO helps providers to communicate with Medicaid clients and with each other, so Medicaid clients receive coordinated care. A RCCO will also help Medicaid clients get the right care when they are returning home from the hospital or a nursing facility, by providing the support needed for a quick recovery. A RCCO helps with other care transitions too, like moving from childrens health services to adult health services, or moving from a hospital to nursing care.

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What is a Primary Care Medical Provider (PCMP)? A primary care medical provider (PCMP) is a Medicaid client's main health care provider. A PCMP is a Medicaid client's medical home, where he/she will get most of their health care. When a Medicaid client needs specialist care, the PCMP will help him/her find the right specialist. All clients enrolled in the ACC have a PCMP. What are the Goals of the RCCO Program? By assisting Medicaid clients in getting connected to a PCMP as their Medical Home and by ensuring the medical, specialty, mental health care and other related services are well coordinated, clients experience in the health care system will improve. Clients will be the primary drivers of their healthcare decisions, but will have the support and assistance they need to achieve their personal healthcare goals. In addition, by having a primary source of medical care that attends to both sick care and wellness and prevention activities, the overall health of Medicaid clients will improve. Finally, when clients are more satisfied and empowered in their healthcare decisions and overall health improves, the total cost of care is reduced.

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Program Measures Emergency Room Visits: Medical care in an emergency room is costly, disruptive, and not always necessary By helping Medicaid clients understand what alternatives they have for using the emergency room for non- emergent conditions, unnecessary use of emergency rooms will be reduced. Inpatient Readmissions Within 30 Days: Inpatient care is necessary for many healthcare conditions and circumstances, and as such is an essential component of the healthcare continuum. However, rapid readmission to inpatient care can often be avoided if Medicaid clients get the assistance they need to ensure timely post-discharge after care with their PCMP, understand their discharge instructions and medications, and have adequate supports to make a successful and sustained transition out of the hospital. High Cost Imaging: This refers to costly diagnostic procedures such as MRIs and CT scans. While these are valuable, necessary tools, they are often unnecessarily repeated when multiple providers are involved in a clients care. By ensuring better communication and coordination of care between providers, some of these duplicative services can be eliminated. Well Child visits added this year as a measure specific to pediatric and family practices

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RCCO Regions

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Benefits of being a PCMP in the RCCO Network $3.00 PMPM FFS Reimbursement Incentive payment Shared Savings Data Analytics and Reporting Capabilities Care Coordination and Medical Management Practice Supports Technical Supports

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Responsibilities of being a PCMP in the RCCO Network Adopt the tenets of being a medical home Especially access criteria similar to all Medicaid Promote quality health care Coordinate care with specialists and referrals Promotes partnership with patient and provider Integrated with other needs Decide care planning together Consistent care geared to your past experiences Provide sick and well care

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Its about Transformation! Using data and analytics is new, scary, unique and extremely productive Attention to cost drivers and incentives for improved care does influence results Knowledge leads to empowerment for all Collaborating across the region is new concept Best practices are shared as they emerge Clinical Transformation happens together

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Kids First Health Care Care Coordination: The Clinic Perspective

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Background on Kids First Health Care Private, non-profit organization 2 Community Pediatric Clinics and 4 School-Based Health Centers in Adams County Our clinics are staffed with 1-2 CPNPs and 1-2 MAs Pediatrician serves as our Medical Director (part-time) Certified Childrens Medical Home Participating in Accountable Care Collaborative (ACC) since February 2011 Added Clinic Manager to take on staff supervision and project management (including the ACC) in August 2012

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Managing Our Participation in the ACC Attending monthly Regional Care Collaborative Organization (RCCO) meetings at Colorado Access Now Quarterly Many great resources and sharing of best practices Getting to know Molly Markert and the expectations of being in the RCCO Getting familiar with the SDAC Dashboard and the patients assigned to us Clean up our patient list Originally contained many adults Sent forms to the state to remove the adults from our attribution Process for removing adults is currently being revised Time spent varies In the beginning 6-8 hours per month in meetings and reviewing data Now with Care Coordination/Delegation responsibilities more time is needed, but it is spread out among many staff members

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Getting Delegated to take on the Care Coordination of our assigned patients Complete Pre-Delegation Audit Tool Review current policies and procedures Revise/Create policies and procedures as necessary Meet with representative from Colorado Access to review Pre- delegation audit tool and our policies and procedures Colorado Childrens Healthcare Access Program (CCHAP) was available to help us with this process

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Pre-Delegation Audit Tool General Care Management Questions Do you have a system to record care management notes, goals and progress? (EMR) Do you have Care Management policies and procedures? Regular communication Follow-up procedures Address barriers to receiving care Cultural beliefs and values, and language barriers Utilization of family or other support systems Creation of Personal Health Record or patient web portal System to stratify/tier levels of care management intervention

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Care Management Staff Training Questions Transitions of Care Questions Quality Management/Quality Improvement Process Internal and RCCO Communication Departmental Focus Areas Reducing inappropriate ER use Preventing avoidable hospital re-admissions Reducing duplicate, unnecessary, or inappropriate imaging Increasing Well Child Checks

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Care Coordination Practices Review our monthly SDAC data (Example) Stratify Patients (High Needs, Medium Needs, Low Needs) High ER usage and high cost imaging services Complex Chronic and Critical (ADHD, epilepsy, med changes) At Risk, Simple Chronic and Stable (Asthma, Obesity, WCC) Track patients monthly on Excel spreadsheet Update patient charts with comments, tasks, care plans, etc. Complete Monthly Metrics Form for Colorado Access Attend monthly meetings with other delegated practices Assign staff members to manage the care for these patients (Providers, MAs, Patient Navigators, etc.) Part time patient navigator (Obesity grant from Kaiser) Full time SBHC patient navigator (CDPHE Expansion Funding) Money from our RCCO and increased visits helps sustain these positions

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SDAC Data

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Care Management Spreadsheet

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Monthly Metrics Assessment and Care Planning Process Number of members with completed assessments Number of members targeted for care coordination Number of members with at least one intervention Population Stratification Process Number of RCCO members in each tier (High, Med, Low) Transition of Care Process Number of inpatient hospital discharges Number of known inpatient hospital discharges that are eligible for transition of care Number of members who participated in transition of care

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Plan for ER reduction Number of high ER utilizers identified Description of interventions applied to high ER utilizers Community Resource Referral Coordination Define your community resource coordination process and the services/organizations with whom you coordinate (food, shelter, education, social needs) Number of members referred to community resources Integrated Care Coordination (across medical neighborhood and RCCOs) Define relationships you have in place to facilitate care coordination process (Behavioral Health)

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Transformation Evaluate changes in data monthly (improvements, set-backs) ER Visits Re-Admits High Cost Imaging WCCs Modify care coordination and data management practices Merge data from previous months to reduce duplication efforts Look into WCC coding practices Engage staff in cycles of rapid improvement (PDSAs) Educate the providers on who these patients are Come up with action plans Spread Best Practices

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Monetary Benefit$ PMPM payments for all attributed patients $3 per month per patient Based on current attribution Incentive payments for performance on Key Performance Indicators (KPIs) Decrease in ER visits, Re-admits, and High Cost Imaging Increase in WCCs Regional outcomes must be met in order to get $ Paid out Quarterly Max payment $1 per member per month Delegated Care Management $3.50 PMPM Varies by Region

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Questions?