Delivering Coordinated Patient Care State of Reform Health Policy Conference Donald J. Rebhun, MD, MSHD National Medical Director DaVita HealthCare Partners November 6, 2015

What Is Care Coordination? Sylvia Care management components: Patient engagement Comprehensive assessments Care plan development Medication reconciliation Advance care planning Patient education Self-management Proper use of/access to network, providers, and services Care coordination Tracking of referrals to other providers or settings of care Test tracking (laboratory, radiology, and other diagnostic procedures) Admission and discharge planning Follow-up appointment tracking DME and home/community-based service needs Information transfer/communication among providers and care settings Difference between care coordination and care management: Care coordination is a component of care management just like medication reconciliation or patient education or care plan development are.   Care management is the concept of taking care of a population of patients across all settings and collaborating with all providers, including community based ones. Can include one or multiple programs depending on population, needs, etc. and would involve not just case managers but also PCPs, Specialists, Pharmacists, Social Workers, etc. Care coordination includes activities like managing/tracking appointments, labs, ordering supplies/DME, scheduling home health, referrals to specialists and other providers, placement, community based services. Care  management is the strategy to reduce costs and increase quality. Care coordination is one of the tactics. Patient-centered Assessment-based Interdisciplinary approach Improving Health Status Reducing Patient Cost Team Based Care

Intervention Action Items One Patient Care Plan ONE Care Plan Goals Intervention Action Items Medications List of Providers/ Contact Information Advance Care Plans Patient Preferences

Where are the Opportunities? Preventive Health Ambulatory Care Management Quality gaps Chronic Conditions Diabetes, Heart failure Respiratory/COPD/Asthma Behavioral health Care Transitions Transitional Care Management Care coordination/navigation Utilization Management Focus Areas

Patient-Centered, Coordinated Care Delivery Primary Care Physicians Wellness & Health Enhancement Programs Specialists 24/7 Patient Support Center Patients & Families Hospitalists Care / Disease Management Coordinated IT Infrastructure Programs not in traditional FFS Built to care for patients with chronic conditions