Collaboration Between a Health Plan and a Community Health System to Improve Care Coordination for a Medicaid Population Karen Michael, RN, MSN, MBA Vice President, Clinical Services, Keystone Mercy Health Plan Grace Lefever, PT, MS, MPH Project Leader Coordinated Care Management, Mercy Health System, Southeastern PA

Who we are Mercy Health System Southeastern PA Keystone Mercy Health Plan (KMHP) Value of Collaboration Aligned organizational goals Opportunity to connect and enhance care coordination

Primary Care Team “Medical Home” Individual and Family Emergency Services Home Health Hospital Community Based Resources Functional IT Care Coordination Specialty Physicians Health Plan Medical Home Proactive plan of care Communication Information systems Transitions of care Activated Patient *NQF Framework Building a New Care Coordination Model

Elements of Mercy Care Coordination Pilot Primary Care Transformation / Embedded KMHP Care Coordinator Hospital Transition Manager (KMHP sponsored RN) Planning for coordinated access and referrals to Multi-Specialty Care Linking with community based providers / resources Patient self-management support – education / wellness Technology enablement Data Management / Program Evaluation

Pilot Outcomes Enhanced Primary Care Coordination (180 members) -Hospitalization admissions reduced (17%), shorter LOS (37%) for a decrease of inpatient days /1000 members of 48% – 30 Day Readmission reduced from 30% pre to 7% after intervention (members not engaged in care coordination changed from 16% in 2008 to 13% in 2009) – Readmission to same hospital increased from 29% to 67% resulting in more care at Mercy – Engaged members had better persistency with the medical home, 26% of non-engaged members were capitated less than 3 months with only 42% for 10 months or longer; Engaged members only 5% were capitated less than 3 months and 67% for 10 months or longer Hospital Based Transition Manager – Successfully integrated health plan transition RN into hospital workflow – Engages members face to face, surveys ED patients about barriers to PCP care – Connects members to KMHP care management and ambulatory care provider Community Based Health Worker – Community outreach services from KMHP visit members lost to contact /overdue for PCP visit – Community health worker team (local Community Development Corp) engaged for follow up visits to members discharged from hospital

– Framework to scale and sustain pilot lessons – Leveraging data / technology – Finding local champions – Adopting work redesign and new team roles – Measuring care coordination – Promoting innovations without aligned financial and performance incentives Challenges